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• • • STATE ID NUMBER 00000058740003 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ] 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ] 09 OTHER: <br /> F. [ ) 01 POLYETHLENE WRAP ( 102 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) PRESSURE ( 05 SUCTION f 106 UNKNOWN f l 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( 7 04 VAPOR SNIFF WELLS ( ) 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 APE NOT RECU:FED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE OAS# IIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( ) O1 ( 1 02 ( ) 03 <br /> ( ) Ol ( 1 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( l Ol ( ) 02 ( ) 03 <br /> ( 1 Ol ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> f J <br /> 01 ( 7 02 f ) 03 <br /> ( 7 <br /> 01 ( 7 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 /> PERSON FILING (SIONATUR PHONE W/AP.EA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> SPA Vb U Loc&(, - kL—fH DKA <br /> CONTACT PERSONY ^aGek PHONE W/AREA CODE <br /> DATE OF LA§T IN43 ECTIOON IN COMPLIIAANCE PERMIT APPROVAL DATE TRANSACTION D.>TE LOC4L PERMIT IO # <br /> 1 1 ( ) Ol YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />