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• i ` 1 <br /> STATE ID NUMBER 00000042162002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER) <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f ) 09 OTHER) <br /> VI PIPING <br />.IA. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> '_HECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> S,,�u" PIPING ( ) 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> 8. UNOERGROU7PR� gOX[ES1 f ] 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN [ ) 07 NONE <br /> (CHECK APPROFRI'M��ir.,. <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL f ) 02 STOCK INVENTOR` ) 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS l j7 `"'IRF. TEST [ ] 09 NONE ( ) 10 OTHER) <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN'' l1NDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO !V-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) <br /> 01 f ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 7 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> f 1 Ol f ) 02 ( 1 03 <br /> f ) <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( )__01 ( <br /> 1 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> f ) 01 YES [ 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />