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STATE ID NUMBER 00000051098002 <br />CONTAINER CONSTRUCTION <br />E. t ) 01 RUBBER LINED ( l 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 ?HENOLIC LINING ( D 05 GLASS LINING <br />(1 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br />F. (X) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( l 04 UNKNOWN ( ) 05 NONE <br />C ) 06 TAR OR ASPHALT P ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: f D 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(`CHECK APPROPRIATE BOX(ES) ( l 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. (,UNDERGROUND PIPING: ( l 01 DOUBLE -WALLED PIPE f ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) 04 PRESSURE 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />t ) 01 VISUAL (X) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT , <br />) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE 1-14-10 OTHER:Ve�edoa_L <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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />t l 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />C l 01 <br />( ) 02" <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />1 ) 02 <br />( ) 03 <br />01 <br />E ) 02 <br />( ) 03 <br />( ) 01 <br />t-) 02 <br />( ) 03 <br />t ) 01 <br />f ) 02 <br />( ) 03 <br />f 01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 N0' <br />THIS FOR W AS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSON F$ ING (SIGNA ) PHONE W/AREA CODE <br />1 <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 ( ) 02 rN0 <br />HSC04-070185 (10/18/85) <br />PAGE 2 <br />