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CONTAINER CONSTRUCTION <br /> E• f ) 01 RUBBER LINED ( ) 02 ALKYD NG STATE IO NUMBER 00000037907001 <br /> LINI <br /> fX) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: EPDXY <br /> LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING <br /> ( 1 06 TAR OR ASPHALT LINING <br /> [ ) 09 OTHER: f 1 03 CATHODIC PROTECTION <br /> !X1 04 UNKNOWN ( ) OS NONE <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: <br /> (CHECK APPROPRIATE BOX(ES) ( 0 0 <br /> 14OUBLE-WALLED PIPE <br /> 8. UNDERGROUND PIPING: PRESSURE ( ) 05 ( 1 02 CONCRETE-LINED TRENCH ( ) <br /> SUCTION ( ) 06 UNKNOWN ( ) 07 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( 1 01 DOUBLE-WALLED PIPE ( NONE <br /> (X1 04 PRESSURE (. ) 05 1 02 CONCRETE-LINED( ) 06 UNKNOWryTREN;H [ ) 03 GRAVITY <br /> VII LEAK DETECTION 07 NONE <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY <br /> f ) 06 GROUND WATER MONITORING WELLS (( 1 04 VAPOR SNIFF <br /> 7 07 PRESSURE TESTEES ( 1 05 SENSOR INSTRUMENT <br /> VIII CHEMICAL COMPOSITION ( ) 09 NONE ( ) 10 OTHER: <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED IO COMPLETE THIS SECTION <br /> ALS STORED IN UNDERGROUND CONTAINERS <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF <br /> STORED STORED KNOWN) <br /> CHEMICAL (DO NOT <br /> 01 02 l ) 03 <br /> USE COMMERCIAL NAME <br /> ( 3 f ) <br /> ( ) O1 ( ) 02 ( ) 03 I <br /> ( ] O1 f J 02 ( ) 03 <br /> [ ) Ol f ) 02 ( ) 03 <br /> [ ) O1 f ) 02 ( ) 03 <br /> f ) Ol ( ) 02 f 1 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO <br /> THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FCt CSG (SIGNATURE) <br /> PHONE W/AREA CODE <br />]R LOCAL AGENCY USE ONLY <br /> MINISTRATING AGENCY <br /> CITY CODE <br /> NTACT PERSON COUNTY CODE <br /> PHONE W/qp¢q CODE <br />(E OF LAST INSPECTION IN COMPLIANCE <br /> ( ) OS YES ( � PERMIT APPROVAL DATE <br /> 02 NO TRANSACTION DATE <br /> LOCAL PERMIT ID # <br /> i4-070185 (10/18/85) <br /> ' PAGE 2 <br />