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0 <br /> STATE ID NUMBER 00000009414003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING [ J 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) ,08 UNKNOWN ( ) 09 OTHER': <br /> F. f l 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING ( 103 CATHODIC PROTECTION t i 04 UNKNOWN (X) 05 NONE <br /> t ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLS PIPE t 102 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH t 103 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( 105 SUCTION { ) 06 UNKNOWN ( ) 07 NONE <br /> VTI LEAK DETECTION <br /> 01 VISUAL (X) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS t Y 05 SENSOR INSTRUMENT <br /> ) 06 GROUND WATER MONITORING WELLS ( d 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 PEQUIRED 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 /> t D O1 ( ) 02 ( ) 03 <br /> t l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> 01 ( D 02 ( ) 03 <br /> l 01 ( ) 02 ( ) 03 <br /> t ) 01 i l 02 ( ) 03 <br /> t ) 01 t ) 02 ( ) 03 <br /> ( l 01 ( l 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> SS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FYLING (SIGN.ATURE) FH NE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE ];;;MIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />