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STATE ID NUMBER 00000048861003 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. (X) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( ) 04 UNKNOWN f 1 05 NONE <br /> f ] 06 TAR OR ASPHALT ( 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 ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) PX7 04 PRESSURE 1 05 SUCTION f 1 06 UNKNOWN l 1 07 NONE <br /> VII LEAK DETECTION <br /> t 1 <br /> 01 VISUAL ( l 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ` ( 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE f 1 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU AVE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 7 Ol ( ) 02 ( 1 03 <br /> ( ) 01 f ) 02 f 103 <br /> 1 ] 01 ( ) 02 ( 103 <br /> ( ) 01 l ) 02 f ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> l ) <br /> 01 ( ) 02 ( 1 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? I ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED ffER THE P ALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON G SI ATU E) PRONE W/AREA CO E <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN ST RATIN AOENCY /� CITY COOS COUNTY CODE <br /> ✓1 <br /> CONT 2 ,CT PlRSON P HE /ARlA COD! <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE IOCAL PERMIT IO # <br /> ( ) <br /> 01 YES ( 1 02 NO <br /> • HSC04-070185 (10/18/85) PAGE 2 <br />