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STATE ID NUM3ER 00000016689001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED f D 02 ALKYD LINING C ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> i ) 07 UNLINED (X) 08 UNKNOWN f 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION [X) 04 UNKNOWN ( ) 05 NCNE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER1 <br /> VI PIPING - <br /> A. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH C ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE fX 05 SUCTION ( ) 07 NONE <br /> VII LEAK DETECTION __I�l <br /> t ) 01 VISUAL (y 02 STOCK INVENTORY l ) 04 VAPOR SNIFF WELLS [ ) 05 SENSOR INSTRUMENT <br /> f ) 06 GROUNrWTER MONITORING WELLS ( ) 07 PRESSURE TEST (XI 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 REPUIRED TO COMPLETE THIS SECTION <br /> CUPRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> C ) 01 [ ) 02 ( ) 03 - <br /> ( .) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 C ) 02 ( 1 03 <br /> ( 1 O1 1 l 02 i ] 03 - <br /> C 1 01 t ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( l 01 ( 1 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDE HE PENA F PERJURY ANO, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON F iU ��PH�JCNEAREA CODE <br /> T F <br /> FOR LOCAL AGENCY USE ONLY <br /> 0 Ism CITY CCDE COUNTY CODE <br /> AOMINISTRATINL9 ASLANCYa <br /> a/�l.•(•.r1�f 7— lfi�(� 1. r <br /> CONTACT PERSON PHONE W/.AREA CODE r <br /> D Gt r 2,0 _���- 7 5 6 <br /> DATE OF LAST INSPE TION IN COMPLIANCE PERMIT APPROVAL. DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 6I YES ( ) 02 NO <br /> � fJ <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />