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STATE ID NUMBER 00000004741002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( } 03 EPDXY LINING ( l 04 PHENOLIC LINING [ ) 05 GLASS LINING <br /> (X) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: <br /> F. t l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( } 05 NONE <br /> ( ) 06 TAR OR ASPHALT t 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (XI 04 PRESSURE i l 05 SUCTION [ ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> t 1 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS i ) 07 PRESSURE TEST ( 1 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 REQUIPED TO COMPLETE THIS SECTION <br /> CUPP=NTLY PPEVIOUSLY DELETE CASU (IP KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t ) 01 ( ) 02 ( 1 03 <br /> t 1 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 t 1 02 ( 1 03 <br /> ( ) 01 S ) 02 ( 1 03 <br /> ( ) 01 ( l 02 ( 1 03 <br /> t ) 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> t ) 01 ( } 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS 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 /> i <br /> PERSON FILING (SIGNA RE) PHONE W/ARE.A CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTkATING AGENCY P/s7 CITY CODE COUNTY CODE <br /> CONTACT PEPSON PHONE W/AREA CODE <br /> L 12 2 � F-2 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID <br /> l� ( ) 01 YES ( ) 02 NO <br /> NSC04-0101&5 114/1$/85) PAGE 2 <br />