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STATE ID NUMBER 00000018549003 <br />CONTAINER CONSTRUCTION <br />E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( l 05 GLASS LINING <br />( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( 1 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER= <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( ) 1 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( l 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br />B. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( 1 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 />( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ,/ <br />( ) 06 GROUND WATER MONITORING WELLS :� 07 PRESSURE TEST ( ) 09 NONE (N 10 OTHER C2Y-40 r5 <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 />CUPPENTLY <br />STORED <br />FREVIOJSLY <br />STOPED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( l 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( 1 03 <br />( ) 01 <br />( ) 02 <br />( 1 03 <br />( ) 01 <br />( ) 02 <br />( l 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 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 l <br />THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSON FT INGIGNATU ) �� PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />1.0M NISTP.4TyT ,- AGENCY <br />CITY CODE <br />COUNTY CODE <br />'4.10,,, <br />{{�u,,,,,,//JJ <br />CONTA T <br />P SON U <br />PHONE W/AREA <br />CODE <br />La J j <br />m <br />DATE OF <br />LAST I�N/SF%-e,CTION <br />IN COMPLIANCE <br />PERMIT APPROVAL DATE <br />TRTRANSACTION 0.47E <br />LOCAL PERMIT ID # <br />3 <br />v1 / - v Y <br />01 YES ( <br />) 02 NO <br />HSC04-070185 (10/18/85) M A . PAGE 2 <br />