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STATE ID NUMBER 00000045099001 <br /> CONTAINER CONSTRUCTION <br /> E. [ ) 01 RUEBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> [ ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER. <br /> F. ( ) 01 POLYETHLENE WRAP l ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE [ ) 05 SUCTIdN ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING, ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( } 07 NONE <br /> VII LEAK DETECTION <br /> ;[ ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> r ) 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 /> CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 f l 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( l 03 <br /> ( J <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 t ) 02 ( l 03 <br /> ) 01 r ) 02 ( 1 03 <br /> r 1 01 C ) 02 1 ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( l 01 f ) 02 ( l 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 ( IGNA. RE PHONE W/AREA CODE <br /> FOR LOCAL AGEN Y 41 ONVY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/ARE.A CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID tt <br /> 0Y YES ( 1 02 NO <br /> SCD4-070185 (10/18551 PAGE 2 <br /> 0 <br />