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• STATE ID NUMBER 00000059784001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ] 03 EPDXY LINING ( 104 PHENOLIC LINING t l 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN f 1 09 OTHER: <br /> F. ( ) 01 POLYETHYLENE WRAP [ 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 7 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER! <br /> VI PIPING <br /> A. ABOVEGROUND PIPING) ( ) 01 DOUBLE-WALLED PIPE ( 7 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING( ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION f 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED 'TES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUP.PENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> f ) 01 ( ) 02 ( ) 03 <br /> f ). 01 ( ) 02 ( ) 03 <br /> [ ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> t ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> i( 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, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATUP.E) 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 /> ( ) 01 YES ( ) 02 N0 . <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> 0 • <br />