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STATE ID NUMBER 00000008339001 <br /> CONTAINER CONSTRUCTION <br /> E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( 103 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ). 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 7 05 SUCTION f 106 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X} 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> [ 7 01 ( 102 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 T ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 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 PE ALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON F ING (SIGNATURE PHONE W/AREA CODE n <br /> R LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITYSOD COUNTY CODE <br /> CONTACT PERSON PHO E W/AREA CODE <br /> E'o��a 2�c S— <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( I <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />