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STATE ID NUMBER 00000038750005 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING C ) 03 EPDXY LINING I ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( 1 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> F. f } 01 POLYETHLENE WRAP t 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN l ) 05 NONE <br /> C ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 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 t 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( 1 05 SUCTION C 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST i ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> YOU CHECKED YES TO !V-F YOU APE NOT RECfUIPED TO COMPLETE THIS SECTION <br /> CUP.=ENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> C 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( ] 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> C ] 01 ( ) 02 ( ] 03 <br /> ( 1 01 ( } 02 t ) 03 <br /> C 1 01 ( } 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FISCCHTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (X) 02 NO v <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE: IS TRUE AND CORRECT. <br /> PERSON F, LING { GNATURE) PHON Lf-ARE CO3 <br /> i <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINIS7RATI4G AGENCYI :3TY CODE COUNTY CODE <br /> err 9 <br /> CONTACT ERSO*fPHONE WIAREA CODE <br /> } [ fit 9q6 - oxv <br /> D4 TE OF LAS INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 20 # <br /> ( ) 02 YES ( l 02 NO <br /> HSC04-070185 (10/1$/851 PAGE 2 <br />