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STATE ID NUMBER C00000124C8003 <br /> CONTAINER CONSTRUCTION <br /> E. t ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( a 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN t ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING. ( ) 01 DOUBLE—WALLED PIPE t ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> B. UNOERGROUND PIPING: t 1 01 DOUBLE—WALLED PIPE f ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION f 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (-K+ 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f l 05 SENSOR INSTRUMENT <br /> '( ) 06 GP.OUNA WATER MONITORING WELLS f a 07 PRESSURE TEST ( l 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> _F YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> C'JPP=NTLY PF.EVTCUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMEPC,AL NA`;E ) <br /> S7CRE0 STORED <br /> f 1 01 ( ) 02 ( ) 03 <br /> [ 1 01 f ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> Ll I <br /> ( ) 01 ( ) 02 ( ) 03 1 iIIIIIII <br /> ( ) 01 ( l 02 ( 1 03 <br /> ( l GI ( 1 02 ( a 03 <br /> I <br /> ( ) 0l ( ) 02 [ ) 03 <br /> ( ) 01 ( 102 ( ) 03111111111111 <br /> ( ) 01 ( a 02 f ) 03 <br /> ( ) 01 ( ] 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l 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 /> CR '!LING (SIGNATURE) PHONE W/AREA CODE fl <br /> �� <br /> FOR LOCAL AGENCY USE ONLY <br /> A.DMINISTPATIN G-NCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE JAREA CODE <br /> y / <br /> DAT- OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # <br /> ( ! 01 YES ( ? 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />