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STATE ID NUMBER 00000036048005 <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED f ) 02 ALKYD LINING C i 03 EPDXY LINING i ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f ) 07 UNLINED (X) 08 UNKNOWN ( l C9 OTHER; <br /> F. i 1 01 POLYETHLENE WRAP i ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE:. <br /> i ) 06 TAR OR ASPHALT t 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: C 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING- ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( } 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( 1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS C ) 07 PRESSURE TEST C ) 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> _F YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) ` <br /> STORED STORED <br /> ( ) 01 C ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t 1 01 ( ) 02 ( ) 03 <br /> C 1 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 C ) 02 ( ) 03 <br /> ( 1 <br /> 01 i 1 02 ( 1 03 <br /> [ 1 01 ( 1 02 ( ) 03 <br /> ( ) 01 i ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( )_03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 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 /> ADMINISTPATING 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 NO <br /> HSC04-07CI85 (10/18/65) PAGE 2 <br />