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STATE ID NUMBER 00000015096006 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( D 02 ALKYD LINING f ) 03 EPDXY LINING ( l 04 PHENOLIC LINING f J 05 GLASS LINING <br /> t 1 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING [ 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN { ) 05 NONE <br /> E ) 06 TAR OR ASPHALT ( } 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE { 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE 1 ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 OCUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X1 05 SUCTION i J 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X1 02 STOCK INVENTORY ( J 04 VAPOR SNIFF WELLS i 1 05 SENSOR INSTRUMENT <br /> { 1 06 GROUND WATER MONITORING WELLS ( 107 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECF'ED YES TO IV-F YOU ARE NOT PEQUIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PRE':ICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( r 01 ( l 02 ( J 03 <br /> ( ) 01 ( 1 02 ( l 03 <br /> i t 01 t l 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> t } <br /> al ( 1 02 ( ) 03 <br /> t ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 [ ) 03 <br /> ( ) 01 ( ) 02 i 1 03 <br /> ( ) 01 i ) 02 [ ) 03 <br /> x CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGEr IS TRUE AND CORRECT. <br /> ts <br /> ON FILING fSIGNAT4;P=_ ) <br /> PHONE W/AREA CODE <br /> D <br /> FOR LOCAL AGENCY USE ONLY <br /> AOM:NISTPATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PEPSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL CATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 01 YES ( ) 02 ND <br /> HSC04-070185 (10/18/85) PAGE 2 <br />