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CONTAINER CONSTRUCTION STATE ID NUMBER 00000004291002 <br /> E. [ ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) <br /> IX) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: OS GLASS LINING <br /> F. f ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f ) 04 UNKNOWN (X1 OS NONE <br /> ( ) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> t ) <br /> 01 VISUAL (X) 02 STOCK INVENTORY [ ) 04 YAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 07 PRESSURE ( ) 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 STOPED <br /> f ) 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 f ) 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f 1 O1 ( ) 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> f l <br /> 01 ( ) 02 ( ) 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> f ) 01 ( l 02 ( ) 03 <br /> ( ) <br /> al ( ) 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 fSIONATUREI PMO NE W/ REA CODE <br /> a3 -5(oi5 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADyZNISTRATING AOENCY / /J CITY COOL COUNTY COD' <br /> CONNTAC(T SON11 /�/GY/}Lal/f[/ ✓ PHO E W/AREA CODE •' <br /> � am 2O9 S'Z -S6/s' <br /> DATE OF LAST NSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) O1 YES f ) 02 NO <br /> MSC04-070185 (10/18/85) A� PAGE 2 <br />