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0 <br /> STATE ID NUMBER 00000018096007 <br /> CONTAINER CONSTRUCTION <br /> E. i 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( } 03 EPDXY LINING C ) 04 PHENOLIC LINING [ l 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN C ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 3 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( J 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS i ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER-- <br /> VIII <br /> THER:VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE N07 REOUIPED TO COMPLETE THIS SECTION <br /> CUPPENTLY PP!VICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STOPED STOPED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( } 02 f } 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 f ) 03 <br /> ( i 01 ( ) 02 ( ) 03 <br /> ( ) 01 € ) 02 ( 1 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( } 01 ( ) 02 ( 1 03 <br /> ( l 01 ( ) 02 { ) 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 (SIGNATURE ) PHONE WiAREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> A:DMINISTPATING AGENCY CITY CODE =COUNTY CODE <br /> CONTACT PERSON PHONE WZAPEA CCnE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 9 <br /> ( ) O1 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />