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STATE ID NUMBER 00000028864002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 103 EPDXY LINING 1 ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION [ l 04 UNKNOWN ( 1 05 NONE <br /> (X) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( l 04 PRESSURE IX) OS SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> [ 1 <br /> 01 VISUAL. (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 OS SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS ( 1 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 /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( l <br /> 01 ( 1 02 ( ) 03 <br /> ( ) O1 ( 1 02 ( ) 03 <br /> ( l <br /> 01 [ 1 02 ( ) 03 <br /> l 101 ( 102 1 103 <br /> f ) Ol ( ) 02 ( ) 03 <br /> f 1 Ol ( ) 02 ( ) 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> [ I <br /> 01 [ ) 02 ( 1 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> a 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 (SIGNATUPE) PHONE W/APEA CODE <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 ( ) 03 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />