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• i <br /> STATE ID NUMBER 00000062887003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYO LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING f ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 105 SUCTION ( J 06 UNKNOWN U(( 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI 15,4 04 PRESSURE f ) 05 SUCTION ( ] 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS W 07 PRESSURE TEST ( ) 09 NONE (7d 10 OTHER: (j�Q_ LA20 k- <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REGUIREO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( J <br /> 01 f ) 02 f 1 03 <br /> f ] <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 f 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> ( ) 01 ( ) 02 ( 1 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 FOR AS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FZ 2NG (SIGNAT ) PHO NEO /AREA /� _3 D <br /> 11 77� <br /> //] <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY ' CITY CODE COUNTY CODE <br /> �5 <br /> CONTAO PERSON _ PHONE W/AREA CODE <br /> jn� l a u 5 8'3l?-52/6 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 3 & 01 YES ) 02 NO <br /> HSC04-070185 (10/18/85) S PAGE 2 <br />