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STATE ID NUMBER 00000049996003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING (X) 05 GLASS LINING <br /> ( ) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 1 05 NONE <br /> ( } 06 TAR OR ASPHALT t ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( } 05 SUCTION ( 1 06 UNKNOWN f } 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH i l 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) (X) 04 PRESSURE f } 05 SUCTION ( l 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY tL*i 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> t ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REOUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( ) of ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( l Ol t J 02 ( ) 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> t J 01 f 1 02 ( ) 03 <br /> ( ) 01 ( } 02 ( ) 03 <br /> ( ) 01 ( } 02 ( ) 03 <br /> ( l 01 t ) 02 ( ) 03 <br /> ( ) 01 ( } 02 ( ) 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, 15 TRUE AND CORRECT. <br /> PERSON FILIN^ (SIGNATURE) [PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> A.DMINIS RATING .AGENCY CITY CODE COUNTY CCDE <br /> L <br /> CONTACT PERSON PHO W/AREA CODE <br /> - `- <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID :t <br /> ( } 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />