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• STATE ID NUMBER 00000000655001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ]((o)) <br /> 1 RUBBER LINED ( l 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 7 05 GLASS LINING <br /> 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER <br /> F. t1 POLY ETH LENE WRAP ( ) 02 VINYL WRAPPING03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> FAABOVEGROUND BOVECKAPPROPRIATE•BOXtES) ( ( 0]104 PRESSURE . P1PE 02 05 SUCTION CON;R06EUNKNOWNTREN 7H 07(NONE3 GRAVITY <br /> PIP 1 <br /> ERGROUND PIPING ( ) O1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> ECK APPROPRIATE BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 1 05 <br /> t ( <br /> 01 VISUAL <br /> INVENTORY <br /> 04 <br /> 007 PRESSUREAPOR F TESTEES )( INSTRUMENT <br /> 09 NONE <br /> 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 PPEVIOUSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 f ] 03 <br /> t ) 01 ( ) 02 ( l 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ] 01 ( ) 02 ( ) 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( I Ol f ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> Els <br /> LOCATEDON AN AGRICULTURAL FARM? ( ) O1 YEStX) 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 CODE <br /> PERSON FILING (SIGNATURE) <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> ADMINISTRATING AGENCY <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> PAGE 2 <br /> MSC04-070185 (10/18/85) <br />