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STATE ID NUMBER 00000011285004 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ] 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN (J „ 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f2a-03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION HH-06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f�O_,O1 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (>.4-07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> eVIII 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 /> , CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( 1 OL ( ) 02 ( ) 03 <br /> f ) 01 f 1 02 ( ) 03 <br /> ( 1 <br /> 01 f 1 02 ( ) 03 <br /> ( ) <br /> 01 f 1 02 f ) 03 <br /> ( )_01 ( ) 02 f 1 03 <br /> [ 1 <br /> 01 ( ) 02 ( ) 03 <br /> f ] 01 ( l 02 f ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> S CONTAINER LOCATED ON AN AGRICULTURAL FARM f 1 01 YES (X) 02 NO <br /> IS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> R°) <br /> PHONE W/AREA CODE <br /> 'E RSO FILI NO (SIG4AT U <br /> OR LOCAL AGENCY USE ONLY O <br /> ADMINISTRATING AGENCY <br /> CITY CODE COUNTY CODE <br /> F. 3BQ o� <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> DATE OF LAST INSPECTION IN COMPLIANCE <br /> O1 YES ( 1 02 NO <br /> _77- PAGE 2 <br /> 3004-070185 (10/18/85) <br />