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STATE ID NUMBER 00000001539002 <br /> CONTAINER CONSTRUCTION <br /> E. 1 ) 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) OS POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f 1 04 UNKNOWN f ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE t ) 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) ( ) 04 PRESSURE fXl 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 30 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT RECUIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PPEVICUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPEO STOPED <br /> f ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 7 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 7 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( 7 03 <br /> f ) 01 ( 1 02 ( 1 03 <br /> f ) <br /> 01 t ) 02 t 1 03 <br /> f ) <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 FORMAfS BEEN CDM ED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON I (S ) PHONE /.4 RE A CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATINGG AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CGDE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID k <br /> ( ) 01 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />