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• STATE ID NUMBER 00000036259 <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( ) 02 ALKYD LINING 1 ) 03 EPDXY LINING l l 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 103 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 109 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE f 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV'F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> f ) <br /> 01 f 1 02 ( ) 03 <br /> I I <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> f 1 01 ( 1 02 ( 1 03 <br /> l ) Ol ( ) 02 I ) 03 <br /> f 1 Ol ( 1 02 ( ) 03 <br /> Ll <br /> ( ) 01 f ) 02 ( ) 03 <br /> I 1 Ol f ) 02 ( l 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> + CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> ITS CONTAINER LOCATED ON AN AGRICULTURAL FARM? I ) 01 YES 1X1 02 NO <br /> i <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATUPE) PHONE W/AREA GOOF <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DAT! OF LAST INSPECTION IN COMPLIANC! PIRMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID R <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br />