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14 <br />STATE ID NUMBER 00000010994003 <br />CONTAINER CONSTRUCTION <br />¢. ( ) 01 RUBBER LINED ( l 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br />°. f ) 01 POLY€THLENE WRAP ( 1 02 VINYL WRAPPING ( 103 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br />( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br />VI PIPING <br />1. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />3. UNDERGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (x) 04 PRESSURE ('* 05 SUCTION l ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />f ) 01 VISUAL fX) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br />f ) 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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />- ( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) O1 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( 1 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( 1 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( 1 02 <br />f ) 03 <br />( ) 01 <br />( 1 02 <br />( ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 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 />iIS FORM HAS BEEN COMP LE ER THE PENAL PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />:EPSON FILING ISIONAT E PHON W,;AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />AGENCY <br />PERSON <br />CITY <br />PHONE W1 <br />OF LAST INSPECTION IINCOMPLIANCE01 YES, ) OE NO IPERMIT APPROVAL DATE (TRANSACTION DATE <br />HSC04-070185 (10/18/85) <br />_e <br />COUNTY CODE <br />-_ay7a- <br />LOCAL PERMIT ID # <br />PAGE 2 <br />