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1 <br /> �. `. <br /> STATE ID NUMBER 00000014787001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING l l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP [ 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION 1 1 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 f 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (XI 05 SUCTION ( 1 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> f 101 VISUAL f ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST (X) 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 /> ( 1 01 ( ) 02 ( ) 03 <br /> l 1 O1 ( ) 02 ( ) 03 <br /> ( l Ol ( ) 02 f ) 03 <br /> ( ) 01 l ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 O1 f l 02 ( 1 03 <br /> ( ) 01 f ) 02 ( l 03 <br /> f ) <br /> 01 ( ) 02 f ) 03 <br /> f 101 ( ) 02 [ 1 03 <br /> ( ) 01 ( ) 02 1 ) 03 <br /> R CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 ) 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 W/AREA CODE <br /> 2 <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 /> f ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />