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too 100 <br /> STATE ID NUMBER 00000037709001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( } 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING ( D 43 CATHODIC PROTECTION (-NIT 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT { ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING ( ) 01 DOUBLE—WALLED PIPE t d 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING- ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 06 05 SUCTION ( D 06 UNKNOWN -E ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS t 105 SENSOR INSTRUMENT <br /> ) 06 GROUND WATER MONITORING WELLS W 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 ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> E ) 01 ( ) 02 ( ) 03 <br /> t 01 ( ) 02 ( ) 03 <br /> `) Ol ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) ,03 <br /> ( } 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> D 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 E ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t l 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGEo IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CO <br /> ADMINISTRATING UNTY CODE <br /> SAN JOA� 1(V LOCAL HEALTH DISTRICT CITY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTIONIN COMPLIANCE ]PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # <br /> 01 YES t ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />