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A <br /> . <br /> STATE ID HUMBER 00090011182003 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINE(? ( l 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (XI 07 UNLINED ( ) 08 UNKNOWN ( l 09 OTHER: <br /> 01 PCLYETHLEN€ WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> i 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( I <br /> 0 <br /> 1 VISUAL (XI 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT --� <br /> f ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER= <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> ±F VOJ CHECKEC YES TO IV-F YOU APE NOT PECUIREO TO =1PLETE THIS SECTION <br /> CUPPENTLY POEVICUSLY DELETE CAS# (IF KNCWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> S73=ED STOPED <br /> f ) 01 ( ) 02 ( 1 03 <br /> I ) 01 ( f 02 ( ) 03 <br /> ( ) 01 ( 1 02 1 1 03 <br /> ( 1 01 ( ) 02 f ) 03 <br /> f ) 01 f ) 02 ( ) 03 <br /> f 1 01 1 ) 02 f 1 03 <br /> f ) 01 ( f 02 ( 1 03 <br /> i 1 01 ( ) 02 ( 1 03 Li1 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 1 1 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 /> HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br />..PERSON FILING (SIGNATUPE ) PHONE W/AREA CCOE <br /> FOR LOCAL AGENCY USE ONLY <br /> :'^:N.S7947'N' AGENCY CIT) CODE COUNTY CODE <br /> C34TF"T FICSON PHONE W/APER CODE <br /> DaTE CF LAST Y4SFECT:ON IN CC PLIAhCE sEvn:r n�'P-011t�11 ��TJ�ON DATE LOCAL PER9IT ID b <br /> 1 0i YES f 1 D2 u3 <br /> iSC04-070185 (10/18/85) PAGE 2 <br />