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STATE ID NUMBER. 00000018549001 <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />( ) 07 UNLINED (X) 08 UNKNOWN ( l 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />VII LEAK DETECTION <br />( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ( 07 PRESSURE TEST ( ) 09 NONE ZAL 10 OTHER=4k'(, <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 <br />STORED <br />PREVIOUSLY <br />STOPED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( l 03 <br />A. ABOVEGROUND PIPING: ( <br />) 01 DOUBLE -WALLED <br />PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />(N 04 PRESSURE ( <br />) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 <br />NONE <br />B. UNDERGROUND PIPING ( <br />) 01 DOUBLE -WALLED <br />PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY 1 <br />(CHECK APPROPRIATE BOX(ES) <br />(X) 04 PRESSURE ( <br />) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 <br />NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ( 07 PRESSURE TEST ( ) 09 NONE ZAL 10 OTHER=4k'(, <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 <br />STORED <br />PREVIOUSLY <br />STOPED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( l 03 <br />( ) O1 <br />( ) 02 <br />( ) 03 I I I <br />( ) 01 <br />( ) 02 <br />( l 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 I I I <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 />PERSON FILING SIGNAT E) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY I CITY CODE COUNTY CODE <br />1 Lac 6L <br />CONTA TPEP.SO L di �PHONE W/AREA CODE <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />/9,- d ( ) 01 YES ( ) 02 NO <br />HSC04-070185 (10/18/85) M, 4, � � PAGE 2 <br />