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STATE ID NUMBER 00000031637001 <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( 7 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE l l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN IXY 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> (44 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> "T] 06 GROUND WATER MONITORING WELLS QA-07 PRESSURE TEST ( 1 09 NONE ( 1 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 /> CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( l 02 f 1 03 <br /> ( ) 01 ( 1 02 f 1 03 <br /> f ) <br /> 01 ( ] 02 ( ) 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> t 1 01 ( ) 02 ( l 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> f 1 <br /> al ( ) 02 ( ) 03 <br /> ( ) <br /> al ( ) 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 /> PEF.SO. FILING (SIGNAT ) PHONE W/AR A CODE <br /> �� <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITU CODE COUNTY CODE <br /> Jo co -.*(1cS� 3 <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES ( ) 02 NO L <br /> HSC04-070185 110/18/851 PAGE 2 <br />