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STATE ID NUMBER 00000.063247002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LININ ( D 04 PHENOLIC LINING t l OS GLASS LINING <br /> S.2Gi1"07 UNLINED (. ) 08 UNKNOWN t' 1 09 OTHER= <br /> F. t ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING t 1. 03 CATHODIC PROTECTION 4 l 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR:OR ASPHALT { } 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: D<) 01 DOUBLE-WALLED PIPE ( )-02 CONCRETE-LINEDTRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) { ) 04 PRESSURE ( l 05 SUCTION t ) 06 UNKNOWN t D 07 NONE <br /> VII LEAK DETECTION <br /> E ) 01 VISUAL 491'02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> 1 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-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 /> i 01 ( 1; 02 ( ) 03 <br /> ( l 01 ( l 02 ( ) 03 <br /> t 1 01 ( l 02 ( ) 03 <br /> ( l 01 ( l 02 t ) 03 <br /> ( l 01 ( l 02 ( ) 03 <br /> 0,1 ( J Q2 ( ) 03 <br /> t ) 01 ( 3 02 ( ) 03 <br /> t } 01 ( ) 02 ( ) 03, <br /> ( 3 01 ( ) 02 ( ) 03 <br /> t l 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES (-X) 02 NO <br /> THIS FORM HAS BEEF( COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON fI2 G (SIGNATUR ) PHONE W/AREA CODE <br /> - 3 f <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 PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES { 7 02 N0 <br /> HSC04-070185 (10/18/85) PAGE 2 <br />