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STATE ID NUMBER 00000001393003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED I ) 02 ALKYD LININGL�G i ) 04 PHENOLIC LINING f ] 05 GLASS LINING <br /> (W 07 UNLINED ( ) 08 UNKNOWN ( ) 09OTHER: <br /> F. [ ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ] 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 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 BOX(ES) (X) 04 PRESSURE t ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> l 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS (7/l 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> =F YOU CHECP:ED YES TO IV-F YOU ARE NOT REOUIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE. COMMERCIAL NAME) <br /> STOPED STOPED <br /> C ) 01 C ) 02 i ) 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> ( ) 01 ( 1 02 f l 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> [ ) 01 [ ) 02 f ) 03 <br /> f ) 01 f l 02 ( ) 03 <br /> f ) 01 ( 1 02 [ ) 03 <br /> [ ) <br /> 01 i ) 02 ( 1 03 <br /> ( ) <br /> 01 [ ) 02 i ) 03 <br /> ( ) 01 ( ) 02 [ ) 03 <br /> �( CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) Cl 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 /> PEP.SO YFILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRA ING AGENCY CITY CODE COUNTY.SXODE <br /> CCNT.ACT PERSON PHONE W�AREA CODE <br /> DAt�7 <br /> LAST,INSPECTION IN COMPLIANCE PERMIT APPPOVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> /✓,_� ( S 01 YES ( 2 02 NO <br /> HSC04-070135 (10/18/&5) PAGE 2 <br />