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STATE. IO NUMBER 00000030765003 <br /> CONTAINER CONSTRUCTION <br /> E. E ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING f ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> f P 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING U ) 03 CATHODIC PROTECTION ( l 04 UNKNOWN (X) 05 NONE <br /> t 3 06 TAR OR ASPHALT t ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION .( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION t ) 06 UNKNOWN t l 07 NONE <br /> VII LEAK DETECTION <br /> { l 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMEN <br /> f } 06 GROUND WATER MONITORING WELLS t 107 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER:�17h j&Mr(XtV'A <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> 3E YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> { l 01 ( ) 02 t ) 03 <br /> t P <br /> 01 ( ) 02 ( ) 03 <br /> f l 01 ( ) 02 ( ) 03 <br /> ( J 01 ( ) 02 ( -) 03 <br /> t ) 01 { ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t. } 01 ( ) 02 ( ) 03 <br /> t" ) 01 ( ) 02 ( ) 03 <br /> { 3 01 ( ) 02 ( ) 03 <br /> t 9' 01 ( ) 02 ( ) 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.H EN COMPETED UNDER THE PENALTY OF PERJURY ANO", TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON IL NATU PHONE W/AREA CODE <br /> Ag- <br /> FOR LOCAL AGENCY LAE ONLY <br /> ADMINISTRATING AGENCY CITY CODE, COUNTY CODE <br /> f4&� U&au& A%w <br /> CONTACT RE,S.Qw PHONE W/ARE.A CODE <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) PAGE 2 <br />