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0 • <br /> STATE ID NUMBER 00000010781001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ] 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN f ) 07 NONE <br /> S. UNDERGROUND PIPING: ( ) O1 DOUBLE-WALLED IPE ( 1 02 CONCRETE-LINED TRENCH (X1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE <br /> ) 05 SUCTION l 7 06 UNKNOWN f l 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE ( ) 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 (00 NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( ) <br /> 01 f ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 f ) 03 <br /> t 1 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> f ) 01 ( 102 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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 /> PERSON FILING fSIGNA ) PHO NE W/AR A CgDE� <br /> FOR LOCAL AGENCY USE ON Y 01K^J LLj1yl (fl <br /> ADMINISTRATING AGENCY CITY CQDE COUNTY CODE <br /> CONTACT PERSON1 V-1-1- PHO E�q RE CQ � ( ✓��� <br /> LJL <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRp NSACTION DAT! LOCAL PERMIT IO # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> -J <br />