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CONTAINER CONSTRUCTION STATE ID NUMBER 00000059799001 <br /> E. ( ) O1 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER <br /> F. f ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING W,4 03 CATHODIC PROTECTION ( ) 04 UNKNOWN f ) 05 NONE <br /> 06 TAR OR ASPHALT ( ) 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ] 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> f 1 06 GROUND WATER MONITORING WELLS ( ) 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) <br /> STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> I ) 01 ( ) 02 f ) 03 <br /> ( ) Ol ( ) 02 f 1 03 <br /> ( 7 Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 f 1 03 <br /> [ ) Ol ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 f ) 03 <br /> [ 1 01 ( ) 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> iIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br />•HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FIL , 0 (SIGNATU ) <br /> PHONE W/AREA CODE <br /> a <br />°OR LOCAL AGENCY USE ONLY <br /> AOMINI TP.ATING AGENCY <br /> �• CITY CODE COUNTY CODE <br /> l <br /> CONTACT PERSON <br /> PHONE W/A EA CODE <br />)ATE OF LAST INSPECTION IN COMPLIANCE <br /> PERMIT APPROVAL GATE TRANSACTION DATE <br /> ( 1 01 YES ( ) 02 NO LOCAL PERMIT iD R <br />�C04-070185 (10/18/85) <br /> PAGE 2 <br />