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• STATE ID NUMBER 00000035679002 <br /> CONTAINER CONSTRUCTION <br /> E. ( J 01 RUBBER LINED f ) 02 ALKYD LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( )- 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION ( ] 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING• C ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> A ) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> a ( 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ] 10 OTHER: <br /> t; <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# IIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> f ) 01 ( 1 02 f 1 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( 1 '03 <br /> ( 1 <br /> 01 ( 1 02 ( 1 03 <br /> ( ) 01 ( 1 02 f 1 03 <br /> f 1 <br /> 01 ( 1 02 ( 1 03 <br /> [ ] <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 f ) 03 <br /> f ) 01 f 1 02 ( 1 03 <br /> f ) O1 ( I 12 ( 1 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 ANO CORRECT. <br /> PERSON FILING (SIGNATURE ) / PHOyAR A CODgew E 6/6n <br /> FOR LOCAL AGENCY USE ONLK- CC <br /> ADMIN ST RATINQQ\ AAGENCY ��pp CITY CODE COUNTY CODE <br /> }DQ 1 t� `T , . l� <br /> CONTAC PERSQN u PHON;;47A CODE_ —� I /` <br /> DATE OF LAST INSIPECTICU SN COMPLIANCE PERMIT APPROVAL DATE JTCRRAANSACTIONN/bDATE ! V LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> f <br />