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STATE ID NUMBER 00000065070002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING t ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER) <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING 1 ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT l ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN t ) 07 NONE <br /> B. UNDERGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION ) <br /> 1 <br /> 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND NATER MONITORING WELLS f 1 07 PRESSURE TEST ( ) 09 NONE 1 ) 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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) 01 ( ) 02 ( ) 03 SOLVENTS <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> t 1 O1 ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> 1 ) <br /> 01 ( ) 02 ( ) 03 <br /> f 1 Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 t ) 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED (N1 AN AGRICULTURAL FARM? f l 01 YES (X1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AN) CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY ` CITY CODE COUNTY CODE <br /> 5 r a <br /> (CONTACT PERSON `/vn�5hl' PHS V W/AREA COOEynl, <br /> CA P <br /> IDATE OF LAST INSPECTION IN COMPLI NCE PERMIT APPROVAL DATE (/TTRA/pNSACTION DATES LOCAL PERMIT ID # <br /> L IL01 YES <br /> n f I 02 NO <br /> HSC04-070185 (05/05/86) PAGE 2 <br />