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N <br />CONTAINER CONSTRUCTION STATE ID NUMBER 00000024754001 <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER.- <br />VI <br />THER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH <br />(CHECK APPROPRIATE( ) 03 GRAVITY <br />BOX(ES) ( 1 04 PRESSURE (Xl OS SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />a <br />( 1 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ( 7 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br />I VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV.F YOU ARE NnT <br />IIS 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) <br />_.'lS6 PHONE W/AREA CODE_ — <br />FOR LOCAL AGENCY USE ONLY <br />ADMIN STRATI O AGENCY <br />inns sec TION <br />CURRENTLY PREVIOUSLY <br />DELETE CAS# (IF KNOWN) <br />STARED STORED <br />CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) O1 ( ) 02 <br />( ) 03 <br />( ) 01 ( ) 02 <br />( ) 03 <br />f ) Ol ( ) 02 <br />( ) 03 <br />( 1 01 ( ) 02 <br />( ) 03 <br />( ) 03 <br />02 <br />( ) 03 <br />P02 <br />02 <br />( ) 03 <br />02 <br />( ) 03 <br />02 <br />( ) 03 <br />02 <br />( ) 03 <br />* CHECK STATE BOARD <br />CHFMTrAI rnnc i 10TT.,.. ....... . <br />IIS 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) <br />_.'lS6 PHONE W/AREA CODE_ — <br />FOR LOCAL AGENCY USE ONLY <br />ADMIN STRATI O AGENCY <br />' <br />CITY CODE <br />COUNTY CODE <br />^ <br />319/ <br />CONTACT PERSON <br />PHONE W/AREA CODE <br />-5'� 7 - <br />DATE OF LAST INSPECTION <br />IN COMPLIANCE <br />PERMIT <br />3 -^5 .•— G <br />( ) O1 YES ( ) <br />APPROVAL DATE TRANSACTION DATE <br />LOCAL PERMIT ID # <br />02 NO <br />M4, <br />HSC04-070185 (10/18/85) <br />PAGE 2 <br />