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STATE ID NUMBER 00000017741001 <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN f 1 09 OTHER: <br /> f ) <br /> 01 POLYETH.LENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> f ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> 'A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE f 102 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 ( 1 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> f l O1 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST fX) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YO'J CHECKED YES TO IV` YOU APE .NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 f ) 03 <br /> ( ) 01 f 1 02 f ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( 102 ( ) 03 <br /> ( ) Ol f ) 02 ( ) 03 <br /> ( ) Ol ( ) 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 /> 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 /> 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 /> ( 1 OS YE <br /> S ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />