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• STATE ID NUMBER 00000038891001 <br /> CONTAINER CONSTRUCTION <br /> E. I <br /> l O1 RUBBER LINED f ) 02 ALKYD LINING ( ) 03 EPDXY LINING l ) 04 PHENOLIC LINING t ) 05 GLA55 LINING(X) 07 UNLINED ( ) 08 UNKNOWN f 7 09 OTHERF. ) O1 PO LYETH LENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER- <br /> VI PIPING <br /> A (CHECK R APPROPRIATE•BOX(ES1 ( ( 01104 PRESSURE P1PE 02 05 SUCTION CONCRETE 06UNKNOWNTREN TRENCH <br /> 07(NONE <br /> 3 GRAVITY <br /> B (NDERGROUNDCK PRIATE.BOXfESI ( (X)1DOUBLE04 PRESSURE-WALLED P205 SUCTION CONCRETE-LINED 06EUNKNOWNTRENCH 07(NONE <br /> 3 GRAVITY <br /> VII LEAK DETECTION <br /> INSTRUMENT <br /> [ ` 01061GROUNDSUAL (WATER MONITORINGX) 02 STOCK NWELLS TORY (( ))007VPRESSUR EAPOR F TESTEES )t 09 NONE05 ENSOR 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 /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> t 101 ( ) 02 ( ) 03 <br /> ( ] 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03. <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( l 02 ( ) 03 <br /> x 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 /> PHONE W/AREA COOS <br /> PERSON FNSIGNATURE) <br /> Y D - 0 <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> ADMINISTRATING A ENCY <br /> '�` PHONE W/AREA CODE <br /> CONTACT PERS N '7 '] <br /> DATE OF LAST INSPECTIONu IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE/ LOCA) PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> PAGE 2 <br /> H5C04-070185 (10/18/85.) <br /> 0 <br />