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STATE ID NUNBER 00000008404003 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING i 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> (Xi 07 UNLINED t 1 08 UNKNOWN ( ) 09 OTHER' <br /> F. ( ) 01 POLYETHL€NE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION 4 ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT E 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE [ l 02 CONCRETE-LINED TRENCH ( 1 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 (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXiES) ( 1 04 PRESSURE ( ) 05 SUCTION ( l 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> t ) 01 VISUAL ( ) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS [ ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS t ) 07 PRESSURE TEST ( 1 09 NONE C 1 10 OTHER= <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT RERUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) 01 ( ) 02 ( ) 03 7 6 8 1 - 5 2 - 9 1 1 1 NOT ON LIST <br /> ( 1 01 ( } 02 t ) 03 <br /> f ) 01 ( ) 02 f ) 03 <br /> 01 i 1 02 f ) 03 <br /> ( 101 f102 ( 113Nlilllllllll -- -_ <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> f ) 01 ( ) 02 ( 1 03 _ <br /> ( 1 01 [ 1 02 ( 1 03 - - - - <br /> ( ) <br /> 01 t ) 02 ( ) 03 - <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 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 CCRRECT. <br /> PE'R5ON FILING (SIGN,ATURE) ----- -- `� PHONE W/AREA CODE -- � <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN--ISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL GATE TRANSACTION DATE LOCAL PERMIT ID # <br /> t ) 01 YES ( ] 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> 0 <br />