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• • STATE ID NUMBER 00000014886007 <br /> CONTAINER CONSTRUCTION <br /> {E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING l ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED f ) 08 UNKNOWN ( 1 09 OTHER'- <br /> F. ( 1 0 POLYETHLENE WRAP [ ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN (X) 05 NONE <br /> ( 6 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION [ ) 06 UNKNOWN ( ) 07 NONE <br /> S. UNDERGROUND PIPING ( ) O1 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION f ) 06 UNKNOWN ( ) 7 NONE <br /> (((VII LEAK DETECTION <br /> I ( 7 <br /> 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS [ 7 07 PRESSURE TEST ( ) 09 NONE f ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REGUIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> [ ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) Ol ( 1 02 ( ) 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ] 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) <br /> al ( ) 02 f ) 03 <br /> ( 1 Ol f 1 02 f ) 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? (X) 01 YES ( ) 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 FILIN3 GNAT RE) PHONE W/AREA CODE �y <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN STRATI N^v G'_NCY CITY CODE COUNTY CODE <br /> fIC <br /> CONTACT P R OaN PHO E W/ARE CODE <br /> �t�t <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />