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0 0 <br /> STATE ID NUMBER 00000006638001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) O1 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( 104 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l l 05 SUCTION ( 1 06 UNKNOWN f 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION f ) 06 UNKNOWN ( 7 07 NONE <br /> VII LEAK DETECTION <br /> (Xl 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE O 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 /> CURRENTLY PREVIOUSLY DELETE CASA( (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( ) O1 (. 1 02 ( ) 03 <br /> ( 1 01 f ) 02 ( ) 03 <br /> ( 101 ( ) 02 ( ) 03 <br /> ( 1 01 ( 102 f 1 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( ) 01 ( 102 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> i ) <br /> 01 f 1 02 ( ) 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> ?� CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> 0 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES fXl 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 /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPL14NCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 1A <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />