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a <br /> STATE ID NUMBER 00000020115001 <br /> CONTAINER CONSTRUCTION <br /> E. t ) 01 P.UBBER LINED ( ) 02 ALKYD LINING ( ] 03 EPDXY LINING ( l 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> (( t 1.07 UNLINED ( l 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( J 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( l 04 UNKNOWN ( J 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER. <br /> VI PIPING <br /> A. ABOVEGROUND PIPING. ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING• ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ] 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL ( ) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER. <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF 'IOU CHECkED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PPEVICUSLY DELETE CAS!( (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED S7,-=ED <br /> ( ) 01 ( l 02 ( J 03 <br /> ( J <br /> 01 € l 02 ( ) 03 <br /> ( l 01 E 1 02 ( ) 03 <br /> C 1 <br /> 01 1 1 02 f ) 03 <br /> ( ) 01 ( J 02 ( ) 03 <br /> C 1 01 ( 1 02 ( ) 03 <br /> ( l 01 t ) 02 ( ) 03 <br /> f l 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( J 02 ( ) 03 <br /> ( ) 01 t ) 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> C[IS ONTAINER LOCATED ON 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 /> .'EPSON FILSN.i LSIGN,4TURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADYSINISTRATING 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 /> ( ) 03 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />