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STATE ID NUMBER 00000024840002 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING i 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( } 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( r 04 UNKNOWN (X) 05 NONE <br /> f ) 06 TAR OR ASPHALT I ) 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( l 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN [ l 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> )10'6 GROUN ATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINFRS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE OAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( ) 01 ( r 02 ( r 03 <br /> ( ) 01 t ) 02 I } 03 <br /> ( l 01 ( ) 02 f ) 03 <br /> { ) 01 ( ) 02 ( 1 03 <br /> ( r 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( l 02 ( ) 03 <br /> ( 1 01 ( ) 02 € ) 03 <br /> ( r 01 [ } 02 ( ) 03 <br /> [ } 01 [ } 02 ( ) 03 <br /> f ] 01 [ l 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LCCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLE D UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> P€RSCN F (SIGNAT RE) PH0NEy�lr1P CO � <br /> � fl�f J <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> _f 741 A.,, ;PAL6Zc t e`n/ Lc <br /> CONTACT PERSON <br /> PHONE WfA COOS �r / <br /> DATE OF LL7AST I SPECTION IN COMPLIANCE PERMIT .APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> •Z_- <br /> / - f ) O1 YES ( ) 02 NO <br /> HSC04-0700185 (IO/18185r PAGE 2 <br />