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STATE ID NUMBER 00000030765004 <br /> CONTAINER CONSTRUCTION <br /> E. (. ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ') 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER': <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( l 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT { } 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE E ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> ('CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t l 05 SUCTION ( ) 06 UNKNOWN E ) 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL (X) 02 STOCK INVENTORY fi ) 04 VAPOR SNIFF WELLS ( } 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED: IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-P 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 /> { } 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t ) 01: ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> t 1 Ql ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) b3 <br /> t ) 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? ( l 01 YES (X) 02 NO <br /> THIS FOR S EEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE) IS TRUE AND CORRECT. <br /> PEPS N IN gSIGN PHONE W/AREA CODE <br /> FOR LOCAL AGENCY ONLY <br /> ADMINISTRATIN2.,&GENCY CITY CODE COUNTY CODE <br /> t�u ),A%=k '�XKL kgzc� 1 _3�;' - <br /> CONTACT PERSON P NE WXAREA CODE <br /> t <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />