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r µ STATE ID NUMBER 00000003452004 <br /> CION tA INER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> { ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-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 RIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS t J 05 SENSOR INSTRUMENT <br /> t 1 06 GROUND WATER MONITORING WELLS tXl 07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CCNTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT FEv.UIRED TO COMPLETE THIS SECTION <br /> CUFRENTLY PPEVICUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STOPED STORED -- <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( l Ol i 1 02 ( ) 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> i ) <br /> 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( ) OZ [ ) 03 <br /> ( } 01 ( l 02 S 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 i ) 02 t ) 03 <br /> ( 1 01 [ 1 02 i 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> N CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FISCONTAINER 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 CORRECT. <br /> PERSON FILING (SIGNATURE) PHPNE W/A EA CODE Cy <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY 1t,r�,JJ CITDE COUNTY CODE <br /> in Q �l'�1 �S-�r(c" <br /> CONTAC PERSON PHONE W/AREA CODE <br /> t � �e5 C 3 _d�� <br /> DATE OF LAST INSPECTION iN CbMPLI.ANCE PERMIT APPROVAL RATE TR4NSAC7IOW DATE LOCAL PERMIT ID <br /> tt <br /> } 01 YES ( } 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/16/85) <br />