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r../ <br /> STATE ID NUMBER 00000017798005 <br /> CONTAINER CONSTRUCTION <br /> E. f ) Ol RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 7 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> f ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( l 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> S. UNDERGROUND PIPING: ( 7 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESIV 04 PRESSURE ( ) O5 SUCTION FX} 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE ( 1 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 /> ECURRENTLYREVIOUSLY Dj03 <br /> (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED02 f( ) 02 (( ) 02 ( <br /> t ) 01 ( ) 02 [ ) 03 <br /> ( l Ol ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 f ) 03 <br /> ( ) <br /> 01 f ) 02 f ) 03 <br /> ( l 01 f ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 f ) 03 <br /> f ) 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 CO PLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FI I. ( I URE) PHONE W/AREA CODE <br /> 'V6 - d L—xr <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCYCITY CODE COUNTY CODE <br /> 2t <br /> CONTACT PEPS N HONE /AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 7 O1 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />