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STATE ID NUMBER 00000043411001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING (X) 03 EPDXY LINING f } 04 PHENOLIC LINING t 1 05 GLA53 LINING 1 <br /> ( 1 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f } 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH i 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( } 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY i 1 04 VAPOR SNIFF WELLS i ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS t } 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 APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY OELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STOPED STC?ED <br /> [ ) 01 ( 1 02 ( 1 03 <br /> ( i 01 ( ) 02 t 1 03 <br /> ( ) (11 ( ) 02 E 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( } 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( 1 02 f ) 03 <br /> t ) 01 ( l 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 113 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FISONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> P_R$ F L NG SIGNA7 E) [PHONE W/AREA CODE�/ ❑ <br /> I <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN'STRATING j-E Y CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/ARE CCD r <br /> DAVE OF LAST j.jyECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE TL <br /> OCAL PERMIT IO 7t <br /> L(�i US�6 ( 1 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />