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STATE ID NUMBER, 00000011758001 <br /> CONTAINER CONSTRUCTION <br /> E. ( } 01 RUBBER LINED ( ) 02 ALKYD LINING [ 1 03 EPDXY LINING ( } 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( } 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION t ) 04 UNKNOWN [ D 05 NONE <br /> (X) 06 TAR OR ASPHALT ( } 09 OTHER. <br /> VI WIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( 1 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE—WALLED PIPE ( 7 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( } 04 PRESSURE (X} 05 SUCTION I 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> 01 VTSUAL (X) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS [ } 05 SENSOR INSTRUMENT <br /> t l 06 GROUND WATER MONITORING WELLS (V 07 PRESSURE TEST ( l 09 NONE ( } 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU AP_ NOT REgUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> t } 01 c ) 02 ( 1 03 <br /> , ( } 01 ( ) 02 ( ) 03111111111111 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> j ( 1 01 ( ) 02 ( ) 03 <br /> ( <br /> 01 ( ) 02 ( } 03 <br /> ( } 01 ( ) 02 ( ) 03 <br /> t 1 <br /> 01 ( l 02 ( ) 03 <br /> �'( l Ol f } 02 ( ) 03 <br /> ( } 01 ( 1 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> I15 CONTAINER LOCATED CN AN AGRICULTURAL FARM? ( 1 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 PILI SIGNATURE RHONE 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 Z} <br /> ( ) 01 YES C ) 02 NO <br /> N`b -070185 (10/18/851 PAGE 2 <br />