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M <br /> STATE ID NUMBER 00000004171001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION IX) 04 UNKNOWN f ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 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-WALLE P PE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) f 1 04 PRESSURE ( 05 SUCTION -fp D7 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (XI 02 STOCK INVENTORY ( l 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 ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( 1 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 /> PERSON FILING (SIGNATURE) - _ PHONE W/AREA CODE <br /> • f zo9-�6� 5�/� <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY a1S72! CITY CODE COUNTY COD@ <br /> -5,13 N LT�Q f!N l ocf+G /1 EAt,T 1 <br /> CONTACT PERSON PHONE W/AREA CODE <br /> F <br /> DATE OR LAST INSPEC ION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />