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CONTAINER CONSTRUCTION <br /> STATE ID NUMEER 0D00000?092003 <br /> RUBBER LINED ( ) 02 ALKYD LINING ( J 03 EPDXY LINING ( <br /> ( ) 07 UNLINED (X) 08 UNKNOWN f 1 Q9 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f ) ( 1 CAT J 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 06 TAP, OR ASPHALT f l 02 VINYL WRAPPING 03 <br /> HODIC <br /> VI WIPING 09 OTHER: <br /> PROTECTION (Xl 04 UNKNOWN i 1 05 NONE <br /> A. ABOVEGROUND PIPING: <br /> (CHECK APPROPRIATE 80)((ES1 ( ) 01 4 PRESSURE ?,PIPE <br /> PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> { 1 04 PRESSURE ) 05 SUCTION ( J 06 UNKNOWN ( ) 07 NONE <br /> B• UNDERGROUND PIPING: <br /> {CHECK APPROPRIATE BOX(ES) { ( OI04 PRESSURE LE DX) 05 SUCTION CONCRETE-LINED TRENCH <br /> 06 KNOWN (NCH <br /> 07NONEGRAVITY <br /> VII LEAK DETECTION <br /> f l 01 VISUAL (X) 02 STOCK INVENTORY ( J 04 VAPOR SNIFF WELLS <br /> ( ( 05 SENSOR INSTRUMENT <br /> ) 06 GROUND WATER MONITORING WELLS ( J 07 PRESSURE TEST ( ) 09 NONE <br /> ) <br /> VIII CHEMICAL COMPOSITION OF ( ) 10 OTHER: <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT R QAUy ED TO <br /> TERIALSSTORED IN UNDERGROUND CONTAINERS <br /> CURRENTLY PREVIOUSLY DELETE <br /> STOPED CAS# tIF KNOWN) <br /> COMPLETE THIS SECTION CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> 01 ( ) 02 [ ] 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> f ) o1 { l 02 ( ) 03 <br /> ( ) of ( ) 02 c ) 03 <br /> ( ) O1 ( ) 02 { ) 03 <br /> [ ) 01 ( l 02 ( J 03 <br /> ( } 01 ( 1 02 { ) 03 <br /> f ) of i ) 02 ( ) 03 Ji I <br />[ ) <br /> 01 ( 1 02 ( ) 03 <br />( J 01 ( ) 02 C ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> S CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 No <br />[S FORM HAS BEEN COMPLETE? UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF <br /> NATURE) MY KNOWLEDGE, IS TRUE AND COP. ECT. <br /> PHON W/AREA CODE ---�-� <br /> R LOCAL AGENCY USE 9 <br /> Y <br /> INISTPATING AGENCY <br /> CITY CODE <br /> TACT PERSON COUNTY CCDE <br /> RHONE W/AREA CODE <br /> E OF LAST NSPECTION IN COMPLIANCE <br /> ( J 01 YES ( ) 02 NO REKNIT APPROVAL DATE TRANSACTION DATE <br /> ..LOCAL PERMIT 10 # <br />