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CONTAINER CONSTRUCTION STATE ID NUMBER 00000035349004 <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 1 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. AH <br /> IPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> ( RIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B. UIPING: ( ) O1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> ( RIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( l 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> �'( 1 01 VISUAL f ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS f l 07 PRESSURE TEST (X) 09 NONE ( 1 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) <br /> STORED STOPED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( l 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( 103 <br /> ( 1 O1 ( 1 02 ( 1 03 <br /> f l Ol ( 1 02 f 1 03 <br /> f ) 01 ( 1 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> f l <br /> 01 ( ) 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES IX) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PER AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON PIlIN6 (SIGNA E _ PHONE W/AREA CODE <br /> '7 23-3/ <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATTING AGENCY ? / 'D�S7 CITY CODE <br /> L/( n/ v G P4 G �.7Y,'L� (TJ COUNTY CODE <br /> CONTACT PERSON <br /> PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( ) <br /> 01 YES f ) 02 NO LOCAL PERMIT ID # <br /> ISC04-070185 (10/18/85) <br /> PAGE 2 <br />