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STATE ID NUMBER 00000018304002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING C ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED € ) 08 UNKNOWN ( ) 09 OTHER. <br /> F. I 1 of POLYETHLENE WRAP ( ] 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN t 1 45 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING- ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) fly SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE tX) 05 SUCTION C } 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS i l 05 SENSOR INSTRUMENT <br /> t ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED 'f ES TO IV-F YOU APE NOT P.EQUIRED TO COMPLETE THIS SECTION <br /> CUPPENTLY PPEVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( ) 01 f 1 02 ( } 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( r 01 ( l 02 ( ) 03 <br /> t } 01 t l 02 ( ) 03 <br /> ( ) 01 ( ) 02 { ) 03 <br /> ( ) <br /> 01 t ) 02 C } 03 <br /> ( ) <br /> 01 ( k 02 C ) d3 <br /> C r <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 tt I <br /> ( ) 01 ( ) 02 C ) 03 P 1 <br /> � CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS 7�il <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 /> PEP.SON FILING (SI^^ ' )Q PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ITY CODE COUNTY CODE <br /> ADMINISTRATING AGENCY I <br /> PHONE W/AREA CODE <br /> CONTACT PEPSON q <br /> DATE OF LAST INSPECTION IN COMPLIANCE <br /> PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PEPMIT Ip # <br /> I ) 01 YES 4 ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />