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STATE ID NUMBER 00000008466002 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING l 1 03 EPDXY LINING f ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> [ 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. l ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> S. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN l ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f l 05 SENSOR INSTRUMENT <br /> ( ) 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 CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 f l 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 f 1 02 ( ) 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> l ) 01 ( l 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> f 7 <br /> 01 ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 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 /> F N FILING (SIGNATUR!�y� PHONE W/AREA CODE <br /> W . �>3�1L0>\ 2.09- a35- wwWN <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTIONIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID )) <br /> l ) Ol YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> �� <br />