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4 <br /> STATE ID NUMBER 00000010516002 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( 1 02 ALKYD LINING C ) 03 EPDXY LINING f ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( J 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: D I <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE C ) 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPP,OPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> EBUNDERGROUND PIPING: ( J 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) D3 GRAVITY <br /> CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( l 05 SUCTION P*-)-06 UNKNOWN ( ) 07 rMnE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f J 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS t ) 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 /> CUPPEN7LY PREVIOUSLY DELETE CASU (IF KNOWN) <br /> STORED STORED CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( ) 01 t ) 02 ( 1 03 <br /> C 1 01 ( ) 02 ( ) 03 <br /> t ) 01 t ) 02 t ) 03 <br /> t 1 01 1 J 02 ( J D3 <br /> ( l al c l 02 ( l 03 � <br /> ( ) 01 C ) 02 ( ) 03 <br /> ( ) 01 ( f 02 ( 1 03 <br /> t l 01 i J 02 t l 03 <br /> t ) 01 ( J 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES (X) 02 NO y <br /> THIS FORM HAS B COMPLETED U ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEP ON FIL G (SIGNATURE) <br /> PHONE /AREA CQ <br /> CS <br /> FOR LOCAL ' ENCY USE ONLY <br /> AOMINISTRATING AGENCY <br /> CITY CODE COUNTY CCDE <br /> CONTACT PERSON <br /> PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IC <br /> ( ) <br /> 01 YES ( 1 02 NO <br /> RSC04-070185 (10/18/85) <br /> 9 <br />