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STATE ID NUMBER 00000036871003 <br /> CONTAINER CONSTRUCTION <br /> E. (: ) OI RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04, PHENOLIC LINING ( 3 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER`: <br /> F. { ) 01 POLYETHLENE'WRAP t ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( i 05 NONE <br /> t ) 06 TAR OR ASPHALT ( ? 09 OTHER= <br /> V PIPING <br /> A. ABOVEGROUt4D PIPING t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( l 06 UNKNO14N j&07 NONE <br /> B. UNDERGROUND PIPING: E ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) Z.04 PRESSURE 05 SUCTION ( i 06 UNKNOWN' t ).07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL 2 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> 06 GROUND WATER MONITORING WELLS 0d 07 PRE , TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COM"POSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES. TO IV-F YOU ARE NOT REQUIRED TO COMPLETE TKIS SECTION- <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL C&O NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> i <br /> 01 ( ) 02 (_ ) 03 <br /> t ) 01 t ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) 01 t ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t 3 01 ( ) 02 ( ) 03 <br /> { ) 01 ( ) 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 CO LETED 'UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON L G (SFG TUP ) r PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMZNISTPAT NG AGENCYCITY CODE COUNTY CODE <br /> CONTACLT PERSON PHONE W/AREA CODE <br /> )eon q ® --.2 Z 91 <br /> DATE OF LAST INSPECTION IN COMPLIANCE ];;;MIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ® ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) ° PAGE 2 <br />