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STATE ID NUMBER 00000018549002 <br />CONTAINER CONSTRUCTION <br />E. ( 101 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( l 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) .26 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 BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) <br />01 VISUAL (X) 02 STOCK INVENTORY(1 040 VAPOR SNIFF WELLS ( ) 05 SENSORINSTRUMENT' A � Zeak' Alec <br />( ) 06 GROUND WATER MONITORING WELLS ( 07 PRESSURE TEST ( ) 09 NONE ( 10 OTHER L/ <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU .APE NOT PEGUIPED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STOKED <br />PP.EVICUSLY <br />STOPED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( 1 03 <br />( ) 01 <br />f ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( l 02 <br />( l 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 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 />PE -++SON FILI)q,G(Z�u <br />RPHONE W/AP.EA CODE <br />FOR LOCAL AGENCY USE ONLY <br />A,DMZNZST TING AGENCY ' CITY CODE COUNTY CODE <br />( <br />CONTgP SCNPHONE W/AREA CODE <br />r `1' <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />( ) 01 YES ( ) 02 NO <br />HSC04-070185 (10/18/85) 1 `, ` o-' PAGE 2 <br />