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wSTATE ID NUMBER 00000066248001 <br /> CONTAINER CONSTRUCTION <br /> E. l 1(01 RUBBER ILINED(Xl 02 ALKYO OB UNKNOWN LINING03 <br /> OTHER! <br /> EPDXY LINING ( 1 04 PHENOLIC LINING l ) 05 GLASS LINING <br /> NED <br /> F. ( )(Ol OLTAR ORTHL NASPHALT 02 <br /> 009 OTHERAPPING ( 7 03 CATHODIC PROTECTION lX] 04 UNKNOWN ( l 05 NONE <br /> VI PIPING <br /> A. ABOVEGROUND PIPING' ( ) 01 DOUBLE-WALLED PIPE [ 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING' ( ) 0 NOWN 07 NONE <br /> DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH l ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) PKI <br /> 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNK ( 1 <br /> VII LEAK DETECTION <br /> l ` 01VISUAL <br /> T02 NIN ( 04 VFWELLS <br /> SENSOR iRSORNTTM <br /> 06GROUND W ER MONITORING WELLS (Wr 07PRESSURETESTJWr 09 NO <br /> VI=FCHEMICAL <br /> cMvCOMPOSITION Or MAToToSSREDINUNDERGROUND CONTAINERS <br /> YOU CHECKED eDRCOMPLETEHIS <br /> CURRENTLY m <br /> LY DELETE CASK (IF KNOWN( <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED <br /> ( ). 01 ( ) 03 <br /> ( 1 01 ( ) 03( 1 012 ( ) 03( ) 012 f ) 03( ) 012 f ) 03( ] O12 ( ) 03( 1 012 ( ) 03ff <br /> 2 ( ) 03 <br /> ) 02 ( ) 03 <br /> ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) O1 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 /> PHONE W/AREA CODE <br /> PERSON FILING (SIGNATURE) <br /> FOR LOCAL AGENCY USE ONLY COUNTY cone <br /> CITY CODE 39 <br /> [DATE <br /> INISTRATING AGENCY <br /> SEan An Local Health District RHONE W/AREA coos <br /> CONTACTKen Be PSON 209-944-2275 <br /> OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> LOCAL PERMIT ID R <br /> 8-26-86 ( 1 O1 YES ( 1 02 NO <br /> V PAGE 2 <br /> HSC04-070185 (08/29/86) <br />