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STATE ID NUMBER 00000062186002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) O1 RUBBER LINED f 102 ALKYD LINING ( 1 03 EPDXY LINING ( 1.04 PHENOLIC LINING f 1 05 GLASS LINING <br /> (X) 07 UNLINED ( 1 .08 UNKNOWN ( 1 09 OTHER: <br /> F• ( ) O1 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATNOO.IC PROTECTION f ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING f ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE..BOXE ES) ( ) -04 PRESSURE I ) 05 SUCTION [ ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (kr 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS QV 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER.: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO.IV-F YOU ARE NOT PEgUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> STORED STOPED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) <br /> al f 1 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> al ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> { 101 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( J 02 f ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) Ol f. ) 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FOR AS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSO FI !NO (SZGNAT <br /> PHO E W/AREA COD <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY <br /> CITY CODE COUNTY CODE <br /> CONTACT PERSON <br /> PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( > O1 YES f ) 02 NO LOCAL PERMIT ID # <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br />