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STATE ID NUMBER 00000059568003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (XI 08 UNKNOWN ( ) 09 OTHER: <br /> F. f 1 01 POLYETHLENE WRAP t 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> ',A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ] 05 SUCTION f ) 06 UNKNOWN f 1 07 NONE <br /> B. UNDERGROUND PIPING ( 1 O1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t 1 04 PRESSURE (X) 05 SUCTION f l 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> ( I <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> ITII 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 /> UPRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 ) <br /> 01 ( ) 02 ( ) 03 I I I <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 I I <br /> t 1 Ol ( ) 02 ( ) 03 <br /> t ) O1 ( 1 02 ( ) 03 <br /> ( 7 Ol t 1 02 ( 1 03 <br /> ( 7 <br /> 01 ( 1 02 ( ) 03 <br /> f 1 01 ( 7 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( ) 01 [ ) 02 ( ) 03 <br /> f 1 <br /> 01 ( 1 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) PHONE II/AREA CODE <br /> D <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 COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 # <br /> ( I 01 YES ( 1 02 NO <br /> NSC04-070185 (10/18/85) PAGE 2 <br />