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• STATE ID NUMBER 00000003452001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 101 RUBBER LINED ( ) 02 ALKYD LINING { l 03 EPDXY LINING i ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. i 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f l 03 CATHODIC PROTECTION (X) 04 UNKNOWN f } 05 NONE <br /> ( ) 06 TAR OR ASPHALT E ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE E ) 02 CONCRETE-LINED TRENCH [ ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( } 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING= ( } 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) E } 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN [ l 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 <br /> VTSUAL IX) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ] 05 SENSOR INSTRUMENT <br /> ( ) Ob GROUND WATER MONITORING WELLS IXl 07 PRE55URE TEST ( 1 09 NONE f ) 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHCk:ED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPRENTLY PPEVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( 1 <br /> 01 ( 1 02 I ) 03 <br /> } 01 ( ) 02 ( 1 03 <br /> f 1 01 ( 1 02 ( 1 03 <br /> ( ] <br /> 01 t ) 02 ( l 03 <br /> f } 01 ( ) 02 ( 1 03 <br /> ( } 01 ( 1 02 t 1 03 <br /> ( ) 01 E ) 02 i ) 03 <br /> ( } <br /> 01 ( ) 02 f 1 03 <br /> ( l <br /> 01 ( ) 02 ( } 03 <br /> ( 1 01 ( } 02 ( l 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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) PH NE W+'A EA CCDE <br /> q 13 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADM� PATING AGENCY CITY E COUNTY CGDE <br /> CONTACT PEP50 PHONE. W E COD4 --A <br /> JL` <br /> �[ (E <br /> DATE' OF LAST INSPECTION IN COMPLIANCE FPEPMIT APPROVAL DATE TRANSACTION DATE LOCAL PEP.MIT IO # <br /> ( ) 42 YES ( ) 02 NO <br /> HSC04-070185 (10/18/851 PAGE 2 <br />