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STATE ID NUMBER 00000060759001 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER= <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION t ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE [ l 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 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) ( 1 04 PRESSURE ( ) 05 SUCTION I ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (XI 01 VISUAL f l 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS [ ) 07 PRESSURE TEST ( l 09 NONE ( l 1G OTHER= <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CH=CKEO YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUP.PENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ? <br /> STORED STORED <br /> (X) 01 ( l 02 t ) 03 OIL AND WATER MIX <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 i l 02 ( ) 03 <br /> ( } <br /> 01 ( ) 02 ( l 03 <br /> 1 } 01 ( ) 02 ( l 03 <br /> ( ) 01 ( } 02 i ) 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> [ l 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 EN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILI ( GNAT ) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY US ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> Qu <br /> r <br /> CONTACTPERSON PH NE W: REA CODE <br /> L. �'� - <br /> HATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE • LOCAL PERMIT ID tt <br /> ( 1 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />