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STATE ID NUMBER 00000042548001 <br /> CONTAINER CONSTRUCTION <br /> E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING t } 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. C l DI POLYETHLENE WRAP t l 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAP. OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE [ 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: i ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN C l 07 NONE <br /> VII LEAK DETECTION <br /> ( ) O1 VISUAL fX) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> I l 06 GROUND WATER MONITORING WELLS ( } 07 PRESSURE TEST ( ) 09 NONE ( 1 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 /> CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f } 01 ( ) 02 ( ) 03 <br /> i 1 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> [ } 01 ( ) 02 ( ) 03 <br /> ( ) 01 [ ) 02 t ) 03 <br /> ( } 01 ( 1 02 f } 03 <br /> ( ) 01 ( 1 02 f 1 03 <br /> f 1 01 ( 1 02 ( D 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FISCONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 O1 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED U14DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> F <br /> SON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMINISTPATING AGENCY CITY CODE COUNTY" CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN CDMPLYaNCE PERMI�APPPCO�)VAL <br /> DATE TRANSACTION DATE LOCAL PERMIT ID <br /> ( L Q1 YES f ) �ND <br /> PACE 2 <br /> HSC04-070185 (10/18/85) <br />