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STATE ID NUMBER 00000038750001 <br /> CONTAINER CONSTRUCTION <br /> E. i ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING i ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> i ) 06 TAR OR ASPHALT i ) 09 OTHER' <br /> VI PIPING <br /> A. 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 /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) CIA 04 PRESSURE ( 05 SUCTION ( l 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> ( l 01 VISUAL (X) 02 STOCK INVENTORY [ ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( l 09 NONE ( ) 10 OTHER' <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT PECUIPED TO CCMPLETE THIS SECTION <br /> CURRENTLY PREVICUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STOP_D STOPED <br /> ( ) O1 ( ) 02 ( 7 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 4 ) 02 ( l 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( ) 01 ( l 02 i ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> [ ) O1 ( ) 02 ( ) 03 <br /> ( ) 01 ( 7 02 ( 1 03 <br /> ( ) 01 ( 1 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 PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON ILING IGNATUR ) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> �CY:INISTP,AT1N AGENCY CITYCODE COUNTY CODE <br /> CONTACT PERSON PHON W/AREA G DE <br /> 1 �- ra <br /> 047E OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> • i <br />