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0 9 - <br /> CONTAINER CONSTRUCTION STATE ID NUMBER 00000018590001 <br /> E- ( 1 O1 RUBBER LINED ( ) 02 ALKYD LINING f l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 7 O1 POLYETH LENE WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRE <br /> NCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE f ) OS SUCTION ( 1 Ob UNKNOWN 1 07 NONE <br /> B. UNDERGROUND PIPING ( 1 01 DOUBLE-WALLED PIPE ( 7 02 CONCRETE-LINED TRNCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X7 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) Ob GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 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 /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> STOPED STOPED CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> f l O1 f l 02 [ 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( J 02 ( 7 03 <br /> f 1 01 ( 1 02 ( 7 03 <br /> f 1 <br /> 01 f 7 02 ( ) 03 <br /> ( ) Ol ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 7 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f Y <br /> 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> FHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) <br /> PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY <br /> CITY CODE CCUNTY CODE <br /> CONTACT PERSON <br /> PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( 7 O1 YES ( ) 02 NO LOCAL PERMIT ID # <br /> SC04-070185 (10/18/85) <br /> PAGE 2 <br />