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STATE ID NUMBER 00000014862004 <br />rnNTATHPO rnNDCTD"rTTnN <br />E.'( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t l 04 PHENOLIC LINING ( 1 05 GLASS LINING <br />(X') 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP t 102 VINYL ,WRAPPING f ) 03 CATHODIC PROTECTION t ) 04 UNKNOWN t ) 05 NONE <br />(X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIING <br />A. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE t l 05 SUCTION ( ) 06 UNKNOWN ( i 07 NONE <br />B. UNDERGROUND PIPING: t ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (l() 04 PRESSURE ( ) 05 SUCTI ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />('7 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f l 05 SENSOR INSTRUMENT <br />I ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />3F YOU CHECKED YES TO IV -F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br />CURPENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />(-) 01 <br />( ) 02 <br />( ) _03 <br />( ) Ol <br />( ) 02 <br />( ) 03 <br />t l 01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />l 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />JIS 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 KNOWLEDGEs IS TRUE AND CORRECT. <br />PERSON FI SIGNATURE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADM'I'NI TRATING AGENCY CITY CODE <br />CONTACT PERSON PHONE W/AREA CODE <br />a <br />DATE OF LAST INSPECTIONjrLIANCE PERMIT APPROVAL DATE TRANSACTION `DATE <br />Y ) 01 YES Y ) 02 NO <br />HSCo4.070185 (10/18/85) <br />COUNTY CODE <br />LOCAL PERMIT ID # <br />PAGE 2 <br />