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CONTAINER CONSTRUCTION `STATE ID NUMBER 00000057920002 <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING f ) EPDXY <br /> (X) 07 UNLINED ( ) 08 UNKNOWN f i 09 OTHER:R: LINING ( ) 04 PHENOLIC LINING ( ) OS GLASS LINING <br /> F• ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 7 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> F(CHECK <br /> EGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> APPROPRIATE BOXES) ( 7 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> RGROUND PIPING: f ) O1 DOUBLE-WALLED PIPE02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> CK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS [ ) 05 SENSOR INSTRUMENT <br /> ( 7 06 GROUND WATER MONITORING WELLS ( 1 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 CASA (IF KNOWN)RED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> O1 ( 7 02 f ) 03J_j 1 0Wes-cW_uar F,x�( 07Ol ( ) 02 ( ) 03 <br /> 01 [ ) 02 ( ) 03 <br /> f l 01 l ) 02 ( 1 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( 7 02 ( ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l 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 /> PERSON FILING f NAT E PHONE W/AREA CODE <br /> /�// <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> f ) 01 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />