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STATE ID NUMBER 00000006268002 <br />CONTAIN<ER CONSTRUCTION <br />E. ( ).01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t') 04 PHENOLIC LINING ( } 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( )'03 CATHODIC PROTECTION t ) 04 UNKNOWN (X) 05 NONE <br />t ) 06 TAR OR ASPHALT ( ) 09 OTHER <br />VIPIPING <br />A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: ( )'01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE { ) 05 SUCTION ( ) 06 UNKNOWN { ) 07 NONE <br />VII LEAK DETECTION <br />{ ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ) 07 PRESSURE TEST t ) 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 P,EOUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (OO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( )' 01 <br />{ ) 02 <br />( ) 03 <br />( ) 01 <br />f 102 <br />( ) 03 <br />t 01 <br />( ) 02 <br />( ) 03 <br />d )' 01 <br />t ) 02 <br />( ) 03 <br />( T 01 <br />( ) 02` <br />( ) 03 <br />{ ) 01 <br />( ) 02 <br />( ) 03 <br />' f ) 01 <br />( 1 02 <br />( ) 03 <br />01 <br />( l 02 <br />( ) 03 <br />{ E l 01 <br />t ) 02 <br />( ) 03 <br /># CHECK STATE BOARD .CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />;I6 CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (X) 02 NO <br />THIS FORM HA BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND: TO THE BEST OF MY KNOWLEDGE: IS TRUE AND CORRECT. <br />P:RSON FIL (S TURE)' _TP HONE /.AREA ODE <br />�FLR LOCAL AGENCY USE ONLY <br />,ACMIN °'TRATTAENCY CITY CODE COUNTY CODE <br />CONTArC? PERSON PHONE W/ PEA CODE <br />X10Y&4 y <br />DATE OF LAST ZNSPECTION IN COMPLIANCE RERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />® ( ) 01 YES ( ) 02 NO <br />�,HSC04-070185 (10/18/85) <br />PAGE 2 <br />I <br />