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STATE ID NUMBER 00000053870001 <br /> CONTAINER CONSTRUCTION <br /> FF. ( <br /> EO6 <br /> RUBBER LI14ED [ ) '02 ALKYD LINING ( ) 03 EPDXY LINING { r 04 PHENOLIC LINING i } 05 GLASS LINING <br /> NLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> ETHLENE WRAP ( } 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONEAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( } 01 OCUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXtES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH t 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION [ 1 06 UNKNOWN ( 3 07 NONE <br /> VII LEAK DETECTION <br /> FC) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT) 06 GROUND WATER MOhiITORING WELLS t ) 07 PRESSURE TEST ( 1 09 NONE ( D 1D OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU C14ECFED `'ES TD IV-F YCU ARE NCT REQUIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STCPED <br /> f r D1 t ) 02 ( 1 03 <br /> 1 01 t ) 02 ( l 03 <br /> ( ) 01 [ ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> { ) 01 ( ) 02 { 1 03 <br /> ( 3 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( r 02 ( l 03 <br /> ( ) <br /> 01 f 1 02 ( ) 03 <br /> ( ) 01 ( r 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> [IS:CO:NTAI�NER:�LOICATED�ON N AGRICULTURAL FARM? l 1 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 /> PHONE W/AREA CODE <br /> it NO � `tI�ATUP ) <br /> � <br /> PERSD 9 - s9�- , ''S <br /> FOR LOCAL AGENCY USE ONLY <br /> kDMINISTP.ATI G AGENCY <br /> CITY C DE COUNTY CODE <br /> ke-a // 4 <br /> CONTACT PERSON PHOpE W/AR A CDE <br /> OATS OF LAST INSPEGT_rON IN COMPLIANCE r PERMIT APPROVAL DATE TRANSACTION DATE LCCAL PERMIT i0 # <br /> ( ) 01 YES [ ) 02 NO <br /> PAGE 2 <br /> HSC04-0701$5 (1D/18!$51 <br />