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STATE ID NUMBER 00000014147001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f l 03 EPDXY LINING ( } 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN f 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( } 05 NONE <br /> { ) 06 TAR OR ASPHALT { 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGPOUND PIPING: ( 1 O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> L(CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE f ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> ERGROUND PIPING' [ ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> ECK APPROPRIATE 80X(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> E ) <br /> 01 VISUAL ( 1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 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 /> ml ( <br /> ELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ) 03 <br /> ) 03 <br /> t ) 01 ( ) 02 ( } 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) (13 <br /> [ 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> i 1 01 ( 1 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> EISCO:NTAI�NER�LOCATEON AGRICULTURAL FARM? ( ) O1 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 W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATIN3 AGENCY <br /> CITY CODE COUNTY CODE <br /> RHONE W/AREA CODE <br /> CONTACT PERSON <br /> OATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT TO # <br /> ( l 01 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />