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STATE ID NUMBER 00000035811003 <br /> CONTAINER CONSTRUCTION <br /> E. t ) 01 RUBBER LINED ( ) 02 ALKYD LINING i 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 04 OTHER= <br /> F. i ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT E 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPIh7G: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 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 ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) O1 VISUAL (XI 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUNO WATER MONITORING WELLS (X1 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 APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPPENTLY PPEVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STOPED <br /> ( ) 01 ( ) 02 t 1 03 <br /> 01 ( ) 02 ( 1 03 1 Li <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( } 01 ( 1 02 ( 1 03 <br /> ( ) <br /> 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( } 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 O1 YES (X) do NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> PERSO )LING I ATUR ) HONE W/APEA CODE <br /> tl <br /> OR LOCAL AGENCY USE ONLY <br /> .ADMINISTRATING AGENCY CITY CODE COUNTY COpE <br /> CONTACT PEPSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PEPMIT ID # <br /> ( ) OI YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />