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• • <br /> STATE ZO NUMBER 00000058740004 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING t 7 05 GLASS LINING <br /> (X) 07 UNLINED t ) 08 UNKNOWN ( ) 09 OTHER <br /> F. ( 1 Ol POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 7 05 NONE <br /> ( ) 06 TAR OR ASPHALT f ) 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 ( ) 0� OOUB LE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESl -04 PRESSURE f 7 05 SUCTION f l 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f 7 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 PREVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME.) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ] 02 ( ) 03 <br /> ( 7 <br /> 01 ( l 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 Ol f ) 02 ( ) 03 <br /> ( ) Ol ( l 02 ( l 03 <br /> ( ) 01 ( 7 02 ( ) 03 <br /> ( ) Ol f ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( l 03 <br /> r CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> ISCONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1YES (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 (SZGNATVR PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING\ AGGEENC rYwJ kLCITY CODE COUNTY CODE <br /> Si�ti1 I T �' C \yT* �L <br /> CONTACT PERSON PHONE W/AREA CODE <br /> GG � <br /> DATE OF LAST=N5_PE.CTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT TO # <br /> QU�6 ( ) 01 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br /> r � <br />