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STATE ID NUMBER 00000011278001 <br /> CONTAINER CONSTRUCTION <br /> E. ( J 01 RUBBER LINED C ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> i ) 07 UNLINED (X) 08 UNKNOWN ( J 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ] 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 3 03 GRAVITY <br /> (CHECK APPROPRIATE 5OX(ES) ( ] 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN !? 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE (X) 05 SUCTION i ) 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> 9w 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (K) 07 PRESSURE TEST { ) 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIPEO TO COMPLETE THIS SECTION <br /> UPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> CTO,RED STOPED <br /> 01 ( ) 02 ( ) 03 <br /> ) al ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 t ) 03 <br /> ( ) a1 ( 1 02 ( ) 03 <br /> i J 01 ( 1 02 ( )_03 <br /> ( 1 01 ( ) 02 ( 3 03 <br /> Ll <br /> ( ) al ( 3 02 ( ) 03 <br /> C ) 01 ( ) 02 i 1 03 <br /> C ) 01 C ) 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 /> PERS^ FILING (SiGN.ATURE) PHONE W/ P,EA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN*STRATXJ,P_AGENCY_ CITY CODE T <br /> UNTY CODE <br /> 1 ?5 <br /> ]NTACTRSOY j PHONE W/AREA CO�DEE�/ <br /> E OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID tt j <br /> ( ) 01 YES ( ) 02 NO <br /> +-070185 (10/13/85) , <br /> PAGE 2 <br />