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�14ww %owl *,.s '.i <br /> STATE ID NUMBER 00000024244001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYO LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER) <br /> F. f ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE l 1 05 SUCTION ( 1 06 UNKNOWN ( 7 07 NONE <br /> VII LEAK DETECTION <br /> f 1 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS t 1 05 SENSOR INSTRUMENT <br /> f ) 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 (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> f ) <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> t 1 01 f ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 Ol f ) 02 ( ) 03 <br /> l ) O1 ( ) 02 ( ) 03 <br /> [ 1 01 [ ) 02 ( ) 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> iF CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? (X) 01 YES ( ) 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 /> PCRSON FILING (SIGNATURE) PHONE W/ARIA CODE <br /> (7 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> �DATZ OF LAST INSPECTION SN COMPLIANCC PlRMIT APPROVAL DATE TRANSACTION DAT! LOCM PERMIT ID # <br /> ( 1 O1 YES l 1 02 NO <br /> ISC04-070185 (10/18/85) PAGE 2 <br />