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*4w <br /> �.► <br /> STATE ID NUMBER 00000018641007 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING l ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED- ( ) 08 UNKNOWN 1 ) 09 OTHER( <br /> F. 1 ) 01 POLYETHLENE WRAP 1 ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION [ ) 04 UNKNOWN (X)' 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING= ( ) 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> l ) <br /> 01 VISUAL ( ) 02 STOCK INVENTORY [ ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ! 07 PRESSURE TEST (X) 09 NONE ( ) 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 CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) O1 ( ) 02 ( ) 03 GLUE RESIDUE AND GLUE RESINS <br /> (X) 01 ( ) 02 ( ) 03 1110181915121 PHENOL <br /> (X) 01 ( ) 02 ( ) 03 15101010101 FORMALDEHYDE <br /> 1X1 01 ( ) 02 ( ) 03 1 1 1 1 1 1 1 1 1 1 1 1 1 DEFOAMER <br /> (X) 01 ( ) 02 ( ) 03 1 3 4 3 9 0 4 I I I I I MAGNESIUM SILICATE HYDRATE <br /> (X) 01 ( ) 02 ( ) 03 11131416131617171 TITANIUM DIOXIDE <br /> ix) 01 ( ) 02 ( ) 03 11101431818131 • TOLUENE (METHYLSENZENE,AROMATIC HYDROCARBON LOW ANALINE) <br /> (X) 01 l ) 02 ( ) 03 171719101914151 • SULFONIC ACID (CHLOROSULFONIC ACID) <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 1 1 1 1 1 1 1 1 1 1 1 1 1 R G(ck-a.-✓ <br /> ■ 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 /> PEOR F&TING (SIGNATURC> PHONE W/AREA CODE/ <br /> QiLilvr+ <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY / - / S_r CITY CODE COVNTY CODC <br /> -SOJA/ 72A N (� 4. J-4(- ��L'r H <br /> CONTACT IA F� 11Vrte(-) v` PHONE W/ARCA COOS <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL OATC TRANSACTION DATE LOCAL PERMIT ID R <br /> -7 ( 1 O1 VES f 1 02 NO <br /> HSC04-070185 (05/05/86) PAGE 2 <br />