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STATE ID NUMBER 000D001%58006 <br /> CONTAINER CONSTRUCTION <br /> E. [ ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ] 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER- <br /> F. f 1 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING f l 03 CATHODIC PROTECTION ( ) 04 UNKNOW? ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING* l ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BDX(ES) fX) 04 PRESSURE 4-*r 05 SUCTION ( l 06 UNKNOWN ( ) 07 HONE <br /> VII LEAK DETECTION <br /> f 1 <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 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 (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) 01 ( 1 02 ( ) 03 HYDRAULIC OIL <br /> ( 1 <br /> 01 ( ) 02 ( l 03 <br /> ( ) 01 ( ) 02 ( ) 03 _ <br /> ( 7 01 f ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> [ 1 O1 l ) 02 ( ) 03 <br /> t ) 01 ( 102 ( 1 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> ( ) D1 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 f ) 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 C TED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FIL (S U E) PycNE W/AREA CODE <br /> /fGtGc_ ( q Z <br /> FOR LOCAL AGENCY USE ONLY <br /> AD MI NI STRATIN ADE NCY CITY CODE COUNTY CODE <br /> CONTAC ER SON ''GG '8 E W/AREA CODE <br /> ©✓/ m <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />