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op0 STATE ID NUMBER 00000005986002 <br /> CONTAINER CONSTRUCTION <br /> EEICERUBBERNED t ) 02 ALKYD LINING ( 1 03 EPDXY LINING f 7 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> D (X) 08 UNKNOWN l 1 09 OTHER: <br /> NE WRAP ( 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION04 UNKNOWN (X1 OS NONE <br /> ASPHALT ( ] 09 OTHER: <br /> VI PIPING <br /> ) 03 <br /> A (CHECK APPROPRIATE BOX(ES) ( ( 01104DOUBLE-WALLED )IPE 02 05 SUCTION CONCRETE-LINED( ) 06UNKNOWNTR(N) 07t 3 GRAVITY <br /> NONE <br /> B (CHECKRAPPROPRIATE- <br /> PPR PRIATE'BOX(ES) ( ( 1104 PRESSURELE(X) 05 SUCTION CON,R 06EUNKNOWNTREN)H 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL ( 1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 105 SENSOR INSTRUMENT <br /> [ ) 06 GROUND WATER MONITORING WELLS (X) 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 APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( 1 01 [ 1 02 ( ) 03 <br /> ( ) Ol ( 1 02 ( l 03 <br /> ( 1 01 f 7 02 ( ) 03 <br /> rf l 02 ( ) 03 <br /> ( ) 02 ( ) 03 <br /> ( ) 02 ( ) 03 <br /> ( 1 02 l ) 03 <br /> ( ) 0203 <br /> ( 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 f 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 ND <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) i /' �/ //1 N PHONE W/AREA CODE <br /> 62-6/z y <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY 1.)I'r/lr CITY CODE COUNTY CODE <br /> ,5W it/ ✓OACQI410V <br /> CONTACT PERSON PHONE W/AREA COaDE <br /> z <br /> D47E 'F LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> /� oV" ( ) 01 YES ( 1 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />