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STATE ID NUMBER 00000048924001 <br /> CONTAINER CONSTRUCTION <br /> E. ( J 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 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 f l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ] 05 SUCTION L ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE [ J D2 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECF. APPROPRIATE BOX(ES) CX) 04 PRESSURE f l 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VTI LEAK DETECTION <br /> fW 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT , <br /> "'T') 06 GROUND WATER MONITORING WELLS (X 07 PRESSURE TEST f ) 09 NONE (XJ 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> _F YOU CHECKED YES TO IV-F YOU ARE NOT REQUZPE0 TO COMPLETE THIS SECTION <br /> CURRENTLY PPEVICUSLY DELETE CAS#. (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 k <br /> [ ) 01 ( 1 02 ( ) 03 <br /> f 1 01 ( } 02 ( ) 03 <br /> ( 1 01 ( ) 02 [ ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( J 03 <br /> t ) 01 ( 1 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS F M HAS BEE COMPLETED UNDER THE-PfQALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PE SO kTt G iSI N TUPE PHONE W/AREA CODE <br /> © <br /> FOR LOCAL AGENCY USE ONLY <br /> A.DMINISTP.ATTNG AGENCYr ` CITY CODE COUNTY CODE <br /> SaSalk To <br /> a. , �'^C4((. <br /> CONTACT PERSON PHONE W/AREA CODE <br /> V C- -4 -20 '* (o - Z2 f)G <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TPANSACTION GATE LOCAL PERMIT ID n <br /> ( 1 01 YES ( Y 02 NO p <br /> ' HSC04-070185 (10/18/85) I T 14(+� � �11V� y �E+CpnCf r f�-�101� <br /> PAGE 2 <br /> �r� <br /> - 7EJ <br />