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STATE ID NUMBER 00000063247001 <br /> CONTAIN-ER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ? 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> 07 UNLINED t ) 06 UNKNOWN ( )':09 OTHERS <br /> F. ( ) 01PPOLYETHLENE WRAP ( ) 02 VINYL WRAPPING d ) 03 CATHODIC PROTECTION ( J 04 UNKNOWN (X) 05 NONE <br /> f ) 06 TAR OR ASPHALT t ) 09 OTHER:` <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f )' 01 DOUBLE-WALLED PIPE f )' 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXtES) ( ) 04 PRESSURE t ) 05 SUCTION ( J 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f?C 01 DOUBLE-WALLED PIPE t ;1 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE X(ES) ( l 04 PRESSURE ( ) O5 SUCTION ( l 06 UNKNOWN f 107 NONE <br /> VII LEAK DETECTION <br /> t ) 01 VISUAL <-Xf 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS C 05 SENSOR INSTRUMENT <br /> J 06 GROUND WATER MONITORING WELLS' ( ) 07 PRESSURE TEST ( ) 09 NONE ( l 10 OTHER: <br /> VIII CHEMICAL COMP:OSITION OF MATERIALS STORED. IN UNDERGROUND CONTAINERS <br /> F YOU CHECKED YES TO IV-:F YOU ARE NOT REgUIR:E$ TO COMPLETE THIS: SE-CTIO'N <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMIOAL- (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t 3 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( } 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> C ) 01 ( ) 02 ( ) 03 <br /> t 3 01 ( ) 0.2 ( ) 03 <br /> 01 ( )-02 ( ) 03 <br /> t ) 01 ( ) 02 (. ) 03 <br /> i l 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> CHZ'CK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES tX) 02 NO <br /> THIS FORM HAI BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON F LIN CSIGNATUf 77 PHONE W/AREA CODE <br /> Ev <br /> FOR LOCAL AGENCY USE GN.LY <br /> ADMINISTRATING AGENCY .CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE: TRANSACTION DATE LOCAL PERMIT ID # <br /> t ): 03 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />