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�.� 1EI STATE ID NUMBER 00000004155002 <br /> CONTAINER CONSTRUCTION <br /> 1 ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINZNG ( 1 05 GLASS LINING <br /> E. ( O1 RUBBER LINED ( 1 02 ALKYD LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ] 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( l 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A ABOVEGROUND <br /> BOX(ES) f l DOUBLE-WALLED01104 ESSUREPIPE 02) 05 SUCTION Cf ) 06EUNKNOWNTR`N) 071NONE3 GRAVITY <br /> B UNDERGROUND <br /> BOX(ES) ( ( 01 4D RESSURELEO(X) 05 SUCTION CO IR 06EUNKNOWNTRENCH <br /> 07f 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE ( 1 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 (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> f 1 01 f 1 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 1 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( l 02 1 ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> OIL ( ) 02 ( ) 03 <br /> f l Ol f 1 02 ( ) 03 <br /> ( ) Ol f 1 02 ( ) 03 <br /> f 1 Ol f 1 02 ( ) 03 <br /> l ) 01 ( 1 02 ( ) 03 <br /> R 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 W/AREA 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 /> ( 1 O1 Y:3 ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />