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STATE ID NUMBER 00000004374001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH E ) 03 GRAVITY <br /> [CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> S. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ] 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN [ ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( l 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 /> CUP.RENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> { J 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( l 03 <br /> ( ) OZ 4 ) 02 i 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 E l 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ] <br /> 01 ( ) 02 ( J 03 <br /> ( l 01 ( ) 02 i ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FISCONTAINER 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 FILINS (SIGNATURE) PHONE W/AREA CODE <br /> 4 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADiNIN2STRATING AGENCY CITY CODE COUNTY" CODE <br /> CONTACT PERSON <br /> RHONE W/AREA CODE <br /> DATE CF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE <br /> LOCAL PERMIT +D it <br /> SNO91 YES { ) <br /> ISC04-070185 (10/18/85) <br /> PAGE 2 <br />