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STATE ID NUMBER 00000044960002 <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: [ ) 01 DOUBLE-WALLED PIPE i ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (,4 05 SUCTION N' i ) 07 NONE <br /> VII LEAK DETECTION <br /> i ) 01 VISUAL (X) 02 STOCK INVENTORY E l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( } 07 PRESSURE TEST ( l 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 ='PLETE THIS SECTION <br /> CURPENTLY PFEVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( ) 01 ( 1 02 [ ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> f ) <br /> 01 t J 02 ( ] 03 <br /> C ) 01 ( 1 02 ( l 03 <br /> ( ) 01 ( J 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> i ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( J 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> risONTAINER 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 L G (SIGN RE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTR.ATZNG AGENCY /.S7 CITY CODE COUNTY CODE <br /> r c c c2 //2 <br /> CONTACT PERSON PHONE W/AREA CODE �6 <br /> ��rd/✓ ,� le��/�����!f� Zai T '—T c�s/fl--�� <br /> DATE OF LAST INSPECTION JIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE l4CAL PERMIT ID Jt <br /> ( ) 01 YES ( ) 02 NO <br /> `SC04-070185 (10/18/85) <br /> PAGE 2 <br />