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CONTAINER CONSTRUCTION STATE ID NUMBER 00000052725001 <br /> E. [ ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f ] 04 PHENOLIC LINING f ) OS GLASS LINING <br /> ( 1 07 UNLINED IX) O8 UNKNOWN f 1 09 OTHER: <br /> F• ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION <br /> 09 OTHER: fX] 04 UNKNOWN f ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES1 ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) -01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 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 /> CUR==-NTLY PREVIOUSLY DELETE CASH (IF KNOWN) <br /> STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> f ) 01 ( 1 02 ( 1 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 t ) 03 <br /> ( 1 Ol ( l 02 ( l 03 <br /> ( ) Ol f 1 02 ( ) 03 <br /> f 1 Ol ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 t ) 03 <br /> i <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 f 1 02 ( ) 03 <br /> ( 1 O1 ( 7 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS 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 KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) <br /> PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br />[ADMINISTRATING AGENCY <br /> CITY CODE COUNTY CODE <br /> ACT PERSONPHONE W/AREA CODE <br /> OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION <br /> ( ) O3 YES DATE <br /> ( 1 02 NO - LOCAL PERMIT ID # <br />(SC04-070185 (10/18/85) <br /> PAGE 2 <br />