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STATE ID NUMBER 00000054749009 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING (X) 05 GLASS LINING <br /> f ) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER! <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION f ) 04 UNKNOWN (XI 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING! ( ) 01 DOUBLE-WALLED PIPE f l 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH 1X1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( l 05 SUCTION f l 06 UNKNOWN l ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> C ) 06 GROUND WATER MONITORING WELLS f 1 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-P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> (X) 01 ( ) 02 ( ) 03 12101014131512141 CALCIUM CHLORIDE <br /> (Xl 01 ( ) 02 ( ) 03 171 7 7 3 1 1 1 3 1 1 1 1 SODIUM CHROMATE <br /> ( 1 01. f ) 02 ( 1 03 <br /> f 1 O1 ( ) 02 ( 1 03 <br /> 1 1 01 ( ) 02 ( ) 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> f 1 Ol ( ) 02 f ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> f ) al ( ) 02 ( ) 03 <br /> R CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTIR)AL FARM? ( ) 01 YES (X) 02 N1 <br /> THIS FORM HAS BEEN COMPLETED UNOT9, THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> PE P.SON PILINS (SIGNATUR PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE NLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PCRMIT ID # <br /> 1 ! O1 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />