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IV- <br /> STATE <br /> ATE ID NUMBER 00000058143002 <br /> CONTAINER CONSTRUCTION <br /> FF ( <br /> ) O1 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X1 07 UNLINED ( 1 OB UNKNOWN l 1 09 OTHER• <br /> ) O1 POLY' <br /> WRAP f 7 02 VINYL WRAPPING l ) 03 CATHODIC PROTECTION 1 1 04 UNKNOWN f 1 05 NONE <br /> IX) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE f 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> S. UNDERGROUND PIPING• ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY - <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> kW-01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f i 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 AVE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 1 01 ( 7 02 ( 1 03 <br /> ( 101 f 1 02 f 1 03 <br /> ( 1 01 l 102 ( 1 03 <br /> ( 1 01 f 1 02 ( ) 03 <br /> ( 1 O1 f ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( ) <br /> al ( 7 02 ( 1 03 <br /> ( 1 01 ( l 02 ( 1 03 <br /> l 1 O1 ( ) 02 ( 1 03 <br /> l ) <br /> 01 [ ] 02 ( 1 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 /> PE SON F NO SI TORE) PHON /AREA ODE q, <br /> .Ci O �� �l l Tf70 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATINO�GENC Y CITY CODE COUNTY CODE <br /> Zot <br /> CONTACT P RSON PH HE W/A EA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPPOVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> f ) O1 YES t ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> '� -.001 <br />