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STATE ID NUMBER 00000038750003 <br /> CONTAINER CONSTRUCTION <br /> E. [ ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> t ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( i 01 POLYETHLENE WRAP [ ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 7 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: [ 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) C ) 04 PRESSURE ( ) 05 SUCTION i ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 OOUBLE-WALLED PIPE,, ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1 04 PRESSURE (5j,,95 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( f 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 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 .APE NOT R.EQUIPEO TO COMPLETE THIS SECTION <br /> CURRENTLY FREV:CUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( i 01 ( ) 02 t ) 03 <br /> ( ) 01 f 1 02 ( 1 03 - <br /> ( ) 01 ( ) 02 ( ) 03 <br /> [ ) 01 ( l 02 ( ] 03 <br /> ( ) 01 ( l 02 1 ) 03 <br /> ( 1 01 E ) 02 ( ) 03 <br /> C ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 C ) 03 <br /> 1 ) 01 ( ) 02 t ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l 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 /> PERS F NG (SIGNATURE) PHOFE W/,AP.E CODE <br /> 4g -FOR LOCAL AGENCY USE ONLY <br /> A.DMINISTRATIN3 AGENCYCITY CODE COUNTY CODE <br /> rc <br /> OE <br /> CONTACT PEP.SOtS [/PHQNP' <br /> ��.��� <br /> DATE OF LAST INSPECTSAN IN COMPLIANCE' ` 1 PERMIT APPROVAL DATE TRANSACTGIION DILATE LOCAL PERMIT ID # <br /> ( ) 01. YES ( ) 02 N0 <br /> HSC04-070185 110/18/85) PAGE 2 <br /> � i <br />