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STATE ID NUMBER 00000062064004 <br /> CONTAINER CONSTRUCTION <br /> P. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 7 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION f 7 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ] 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 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 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( l 05 SUCTION ( ) 06 UNKNOWN f ) 01-NONE <br /> VII LEAK DETECTION <br /> ( ) OS VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ) 07 EEESSURE TES ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COKPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ] Ol ( ) 02 ( ) 03 <br /> ( ). 01 ( ) 02 ( ) 03 . <br /> ( 7 01 ( ) 02 ( ) 03 <br /> ( 1.01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( l Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 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 F NO IO ATPH E W/AREgC,� <br /> FOR 0CAL AGENCY SE ONLY S J <br /> •DMI"�-STPATING dGENCY CITY CODE COUNTY ODE <br /> Gtr/aa �inAoeal� alLl D%l�i%�f 3v <br /> CONFA `DN Ale <br /> J e P NE/W/ARE 001�/� <br /> DATE OF JAST <br /> ;NNNSSSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TTRRANSACTIOJN DATE LOCAL PERMIT ID # <br /> 01 YES ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> • L1 � • <br />