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CONTAINER CONSTRUCTION STATE ID NUMBER 000000658620o1 <br /> E• ( ) 01 RUBBER LINED <br /> 07 UNLINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f 1 (X) 08 UNKNOWN ( 1 09 OTHER: <br /> F• ! ) O1 H WRAP <br /> 06 TAROR <br /> ASPHALT ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 OS NONE <br /> VI PIPING <br /> A. ABOVEGROUND PIPING; ( <br /> C 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> 8. UNDERGROUND L EAPPROPRIATE <br /> BOX ES) ( ) 04 PRESSURE ( ) 05 SUCTION (XI 06 UNKNOWN ( ) 07 NONE <br /> (CCHHECCKKAPPROPRIATE <br /> PIPING:OPRIATE BOXES) ( ) 01 DOUBLE-NALLED PIPE ( ) 02 CONCRETE-LID TRENCH ( ) 03 GRAVITY <br /> VII LEAK DETECTION CONCRETE-LINED( 104 PRESSURE f 1 OS SUCTION ( ) 06 UWWN ( ) 07 NONE <br /> ( 1 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 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 DELETECAS# (IF KNOWN) <br /> STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) OS ( 1 02 f ) 03 <br /> f 101 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> 1 ) 01 f ) 02 ( ) 03 <br /> l ) <br /> 01 ( ) 02 ( ) 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> f l <br /> 01 1 l 02 ( ) 03 <br /> ( ! 01 l ) 02 ( ) 03 <br /> I ) O1 f ) 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 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 /> ( ) <br /> 01 YES l l 02 NO <br /> PAGE 2 <br /> HSC04-070185 (08/29/86) <br />