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STATE ID NUMBER 00000038474003 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 103 EPDXY LINING ( ) 04 PHENOLIC LINING i ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 06 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP { ) 02 VINYL WRAPPING i ] 03 CATHODIC PROTECTION ( } 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( 109 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE E 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> F01 VISUAL iX) 02 STOCK INVENTCRY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> 1 06 GROUND WAFER MONITORING WELLS ( ) 07 PRESSURE TEST f l 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED YES TO IV-F YOU APE NOT PFgLJIPED TO COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 [ J 02 ( J 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 [ 102 ( ) 03 <br /> ( J <br /> 01 E ) 02 ( ) 03 <br /> ( 1 01 t ) 02 ( ) 03 s i� <br /> ( ) 01 F } 02 ( J 03 <br /> [ } 01 ( 1 02 ( } 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> 01 i J 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE' LISTING FOR POSSIBLE SYNONYMS <br /> FISCONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES IX) 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 /> FE ON (SIGNATURE ) RHONE W/AREA CODE <br /> i <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATINENCY CITY <br /> CODE COUNTY CODE <br /> CONT A EPS, PHONE W/AP A CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 `r ES ( ) 02 NO <br /> HSC04-070185 (10/18J85D <br /> PAGE 2 <br />