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STATE ID NUMBER 00000018304003 <br /> CONTAINER CONSTRUCTION <br /> E. { ) 01 RUBBER LINED ( ) 02 ALKYD LINING E ) 03 EPDXY LINING ( l 04 PHENOLIC LINING t 1 05 GLASS LINING <br /> (X) 07 UNLINED ( l 08 UNKNOWN ( ) 09 OTHER. <br /> F. f ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN i ] 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: i ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY C ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS E ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF Y'OU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( 1 01 ( ) 02 ( ] 03 _ <br /> ( ) 01 ( 7 02 ( ) 03 <br /> ( ) 01 t ) 02 ( 1 03 <br /> ( 3 01 i 1 02 ( ) 03 <br /> ( 1 01 f 1 02 f l 03 <br /> ( l <br /> 01 ( 1 02 E ) 03 <br /> C 1 01 ( ) 02 [ ) 03 <br /> ( i 01 ( ) 02 ( 1 03 <br /> [ ) 01 ( ) 02 t ) 03 <br /> ( ) 01 ( 1 02 1 ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? �( ) 01 YES (X) 02 NO Y <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANDS TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILIN3 (SIGNATUREf FPHe �At�EA334- 335 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHO E W/AP A CODE <br /> �r n � r^a_ a '�°t 3q-33S� <br /> DATE OF LAST INSPECTION IN COMPLIANCE JPEPMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 01 YES ( 1 02 NO <br /> HSC04-070185 ila/18lB5) PAGE 2 <br />