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STATE ID NUMBER 00000061953001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> f. ( ) 01 POLYETHLENE WRAP ( ] 02 VINYL WRAPPING ( 7 03 CATHODIC PROTECTION l 1 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ) 05 SUCTION ( ) 06 UNKNOWN f 7 07 NONE <br /> VII LEAK DETECTION <br /> { 1 01 VISUAL (X) 02 STOCK INVENTORY ( 7 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS !X) 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( ) 01 ( 1 02 I 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) Ol ( 1 02 ( 1 03 <br /> I 1 01 ( ) 02 I 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( 1 03 <br /> ( ) Ol ( ) 02 ( ) 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 FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PE ON FILING (SIGNATURE) PHONE 07"z <br /> CODE <br /> R LOCAL AGENCY USE ONLY <br /> ADMIyS STRAT I N�f�A W;kz Ir"e ��i(� � CITY CODE COUN'C�YOODE <br /> CONTTAG�R/,a^CT 3( N �n J PHONE W/AREA CODE / 3 <br /> J O ' Z <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 3 2 71k, OS YES ) 02 NO <br /> HSC04-070185 (10/18/85) MPAGE 2 <br /> /', <br />