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STATE ID NUMBER 00000034927002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( l 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( l 05 NONE <br /> ( ) 06 TAR OR ASPHALT i ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGRCUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 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) L>f 04 PRESSURE_dr SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> l <br /> 01 VISUAL (lG 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS (X) 05 SENSxOR' INSTRUMENT <br /> r <br /> �"Tl 06 GROUND WATER MONITORING WELLS t�) 07 PRESSURE TEST ( ) 09 NONE X10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES T„ IV-F YOU ARE NOT REQUIP.ED TO COMPLETE THIS SECTION <br /> CURRENTLY PRE`JiOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE CCMMERCI.AL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( ) <br /> 01 ( 1 02 ( l 03 <br /> f l 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( l 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> ( l <br /> 01 ( l 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( l 03 <br /> ( ) <br /> 01 ( I 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS 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 /> PER - FILING (SIGN.ATUPE) r. PHONE W/ARE.A CODE <br /> 3� <br /> FOR LOCAL AGENCY USE ONLY <br /> A.CMINISTP.A.TIN3 AGENCY CITY CODE COUNTY CODE <br /> SAN 10AMIN POCAI, HEAL?H DISTRICT <br /> CONTACT PERSON PHONE W/AREA CODE <br /> U M er � r I '�U - y- 3 <br /> DATE OF LAST INSPEOTION Fi( <br /> COMPLIANCE PERMIT .APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID <br /> S �f )/O 1 YES ( 02 NO <br /> HSC04-070185 (10/16/85) " 'w` #'�— PAGE 2 <br />