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STATE ID NUMBER 00000011236001 <br /> CONTAINER CONSTRUCTION <br /> E. (X) 01 RUBBER LINED ( ) 02 ALKYL) LINING ( 1 03 EPDXY LINING f l 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (XI 05 NONE <br /> ( ) 06 TAR OR ASPHALT l ] 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 ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05,SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL (X) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS f l 05 SENSOR INSTRUMENT <br /> [ ) 06 GROUND WATER MONITORING WELLS f ] 07 PRESSURE TEST ( ) 09 NONE ( ) 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 CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ] 01 f ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 f 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 f ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> I5 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 /> P SON FI NG (SIG ) PHONE W/AkEA ODE 7 <br /> FOR CAL AGENCY USE ONLY �� �7 Y <br /> ADMINIST TING �AGEUC , l 4e9 CITY CODE COUNTY CODE <br /> CONTACT PEPS=N /V�V PHONE W/AR� C00E </' <br /> DATE OF LAST Iy$P41LCTIDN IN COMPLIANCE D PERMIT APPROVAL CAT TRANSACTION GATE LOCAL PERMIT ID # <br /> /!� ( 7 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />