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�.. <br /> STATE ID NUMBER 00000000724007 <br /> CONTAINER CONSTRUCTION <br /> FF. ( <br /> 01LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> X):RUBBER07 UNLINED ( ) 08 UNKNOWN 1 ) 09 OTHER= <br /> O1 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 O4 UNKNOWN (X) 05 NONE <br /> ) 06 TAR OR ASPHALT ( 109 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING) ( 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENC ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f ) 05 SUCTION ( 1 06 UNKNOWN 07 NONE <br /> B. UNDERGROUND PIPING' ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH l ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE f ) 05 SUCTION ( 1 06 UNKNOWN f l 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 01 VISUAL 1X1 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 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 CASA (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (XI 01 ( ) 02 1 ) 03 WEED OIL (WEED KILLER) <br /> ( 1 <br /> 01 ( ) 02 1 ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f l 01 ( ) 02 ( ) 03 <br /> ( ] Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br /> ( 7 <br /> al ( ) 02 ( 1 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER 0 TED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS E COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (S NAT C1 PHONE W/AREA CODE <br /> FOR LOCAL A ENCY USE ONLY <br /> ADMINISTRATING AENCY lCITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID it <br /> ( ) <br /> 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />