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STATE ID NUMBER 00000005987002 <br /> CONTAINER CONSTRUCTION <br /> E. t 1 01 RUBBER LINED C ) 02 ALKYD LINING ( ] 03 EPDXY LINING ( ] 04 PHENOLIC LINING C } 05 GLASS LINING <br /> f ) 07 UNLINED (X) 08 UNKNOWN i ) 09 OTHER: <br /> F. ( } 01 POLYETHLENE WRAP C } 02 VINYL WRAPPING f } 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT C l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( } 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( l 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) ( 1 04 PRESSURE (X) 05 SUCTION [ ] 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL f 02 STOCK INVENTORY f l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROU( TER MONITORING WELLS (X) 07 PRESSURE TEST f 109 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED fES TO IV-F YOU APE NOT REQ^JIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STCRED STORED <br /> ( ) 01 t ) 02 ( ) 03 <br /> ( l 01 ( ) 02 C 103 <br /> ( ) 01 ( ) 02 ( } <br /> ( I01 ( 102 f103fIIIIJI IIIA <br /> C 1 01 <br /> i 101 ( 102 ( } 03 <br /> f } O1 f 1 02 C l 03 - <br /> } 01 ( 1 02 f ) 03 <br /> ( 101 ( 102 ( ) 031llllll. IIIIII <br /> ( l 01 ( ) 02 C ) 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 /> 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 /> / y <br /> FOR LOCAL AGENCY USE ONLY �7 <br /> PpMINISTPATINC, AGENCY CITY CODE COUNTY CODd <br /> CONTACT PERSON r � C�., PHONE W/AREA CODE <br /> DATE OF LAST INSREC ION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT :0 <br /> o� C 1 O1 YES ( } 02 NO <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br /> �► i <br />