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0 <br />0 STATE ID NUMBER 00000031604002 <br />CONTAINER CONSTRUCTION <br />E. ( ] 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING C 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING C ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (XI 05 NONE <br />( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( l 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN (Xf 07 NONE <br />B. UNDERGRCUNO PIPING: C ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOXCES) ( 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN C ) 07 NONE <br />VII LEAK DETECTION <br />f 1 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS C l 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS (k'f07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER: <br />I VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />*_# YOU CHECY.EO YES TO IV -F YCU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br />CURRINTLY <br />STORED <br />PREVIOUSLY <br />STOR50 <br />DELETE CA S# (IF KNOWN) CHEMICAL (OO NOT USE COMMERCIAL NAME) <br />f ) 01 <br />C ] 02 <br />( ) 03 1j <br />( 1 01 <br />( 1 02 <br />( ] 03 <br />( a 01 <br />( 1 02 <br />( 1 03 <br />I C ] of <br />( 1 02 <br />( ) 03 <br />( 1 01 <br />C ) 02 <br />( l 03 <br />( } 01 <br />( ) 02 <br />( ) 03 <br />f 1 01 <br />( ) 02 <br />C ) 03 <br />01 <br />( l 02 <br />( ) 03 <br />( ] O1 <br />( 1 02 <br />( ) 03 <br />C ) 01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />5 CONTAINER LOCATED ON AN AGRICULTURAL FARM? € ) 01 YES (4'02 NO <br />IS FORM HAS BEEN COMPLETED 9NDfR THE PENALTY OF PERJWF T ANU, IU IMt tstZ5( Ur rll NNUHLCUUC, la IrUr Nrvu l.UrML6i. <br />EPSON FILING (SIGNATUPE)J,,� e �%%� F PHONE W/AREA CODE ' <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY <br />CONTACT PERSON <br />DATE OF LAST INSPECTION IN CCMPLIANCE <br />( ) 01 YES ( ) 02 NO <br />0 HSC04-070185 (10/18/85) <br />CITY CODE (COUNTY CODE <br />PHONE W/AREA CODE <br />PERMIT APPROVAL DATE ITRANSACTION DATE ILOCAL PERMIT ID #< <br />0 is <br />PAGE 2 <br />