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STATE ID NUMBER 00000011195001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED 1 ) 02 ALKYD LINING 1 ) 03 EPDXY LINING 1 ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1X1 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING 1 ) 03 CATHODIC PROTECTION 1 1 04 UNKNOWN (X) 05 NONE <br /> 1 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION 1 1 06 UNKNOWN l 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> I ) 06 GROUND WATER MONITORING WELLS 1 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> I! YOU CHECKED YES TO IV-F YOU ARE NOT PEOU:RCD TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK III KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 ! 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( 1 02 l 103 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> 1 1 Ol 1 ) 02 ( ) 03 <br /> 1 ) Ol ( 1 02 ( ) 03 <br /> 1 ) Ol ( 1 02 ( ) 03 <br /> ( ) al ( ) 02 1 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) al ( ) 02 1 ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> R CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FORK HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON RILINO fSION4TVRE) PHONE W/AREA COOK <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTR4 IND AGENCY I 1 S CjIY CODE COUNTY CODE <br /> CONT PERSON !`-IT PHONE W/AR�A COyC <br /> DATE 01 )AST INSPECTION NC[ PERMIT APPROVAL DATE IRAN LOCAL PCPM:T ID R <br /> t 1 <br /> 01 YES t 1 13 NO <br /> NSC04-070185 (10/18/85) PAGE 2 <br /> 1/ <br /> r <br />