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STATE ID NUMBER 00000010562003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING [ l 04 PHENOLIC LINING ( 7 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( l 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 BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f 1 01 VISUAL 06 02 STOCK TNVFUTnaY [ ) 04 VAPOR SNIFF WELLS f l 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUNDWATER MONITORING WELLS W)) 07 PRESSURE TEST (X) 09 NONE ( 1 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 /> CUP-RENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 .f 1 03 <br /> ( ) O1 ( 1 02 ( 1 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 7 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( 1 03 <br /> ( ). 01 ( 102 ( 7 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 /> PERS ° FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMI 'nP.AT fy AGENCY�j� �/ , _/� CITY CODE COUNTY CODE <br /> MJ�/LYj <br /> CO NTA T PERSON <br /> PH NE W AREA CODE <br /> Zo9flyf/fr-o/C6� <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ��Za/fid ( ) 01 YES ( ) 02 NO <br /> ASCO4-070185 (10/18/85) <br /> PAGE 2 <br /> �y5 <br />