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STATE ID NUMBER 00000004529001 <br /> CONTAINER CONSTRUCTION <br /> E. i ) 01 RUBBER LINED [ ) 02 ALKYD LINING f ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> l ) 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f l 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 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 I ) 07 NONE <br /> B. UNDERGROUND PIPING= ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH (X) 03 GRAVITY p <br /> (CHECK APPROPRIATE BOXES) ( 104 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( 107 NONE <br /> VII LEAK DETECTION <br /> E-K) 01 VISUAL � 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> ( )106V <br /> GROUND WATER MONITORING WELLS ( J 07 PRESSURE TEST d 1 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 /> CURRENTLY PR=EVIOUSLY DELETE CASH (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( J 01 ( 102 i 1 03 Ll <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( 1 01 f 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( l 03 <br /> ( J <br /> 01 ( ) 02 1 ) 03 <br /> f l 01 ( I 02 ( ) 03 <br /> i ) 01 ( D 02 f ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ] 01 ( l 02 ( ] 03 <br /> ( 1 <br /> 01 ( l 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FISCONTAINER 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 F NG ( IGNATURE) V�t/ (� PHONE W/.AREA CODE <br /> �. <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING A NCY CITY CODE COUNTY CODE <br /> �a cnc <br /> CONTA T fEPSCN PHONE W/ REA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> i ) O1 YES e ) 02 NO <br /> HSC04-070185 (10/I8t851 <br /> PAGE 2 <br />