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STATE ID NUMBER 00000004529002 <br /> CONTAINER, CONSTRICTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING [ ] 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ] 05 GLASS LINING <br /> ( 1 07 UNLINED (X) 08 UNKNOWN ( ] 09 OTHER. <br /> F. f 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING [ ! 03 CATHODIC PROTECTION f ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: [ ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) [ ) 04 PRESSURE f ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) i l 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> Hf') 01 VISUAL (�1 02 STOCK INVENTORY i 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS [ ) 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 RECJIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 f } 02 ( 1 03 <br /> ( ) 01 ( J 02 ( l 03 <br /> ( ) 01 ( ) 02 ( ) 03 ( 1 [ <br /> ( ) 01 f } 02 ( 1 03 <br /> ( ) Oi ( ] 02 ( ) 03 <br /> ( ] 01 ( l 02 ( } 03 <br /> ( ] 01 ( 1 02 f ] 03 <br /> ( ) 01 ( l 02 ( 1 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> i 1 01 ( 1 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS COfTAINER LOCATED ON .AN AGRICULTURAL FARM? ( 1 01 YES (X1 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 P L NG (SIGNATURE) �] PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATI_V-AGENCY CITY CODE COUNTY CODE <br /> ( Imautu1 <br /> CONTACT P PSCN PHCN W/AR A CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES t ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> • i <br />