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STATE ID NUMBER 00000054749002 <br /> CONTAINER CONSTRUCTION <br /> P( ) <br /> 1 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING l 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ) 07 UNLINED ( 1 08 UNKNOWN ( 1 09 OTHER: <br /> l POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION f 1 04 UNKNOWN (X) 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 ( 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 ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l 1 OS SUCTION 1 1 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL ( 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST 1X1 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 CAS# (IF KNOWN( <br /> STORED STORED CHEMICAL IDO NOT USE COMMERCIAL NAME) <br /> (X) 01 ( ) 02 ( ) 03 IS I 7 5 1 5161 1 1 1 1 1 1 PROPYLENE GLYCOL <br /> ( ) 01 ( 1 02 ( ) 03 <br /> 1 1 Ol ( 1 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> f 1 01 f 1 02 ( ) 03 <br /> ( ) O1 f ) 02 ( ) 03 <br /> ! l Ol ( 1 02 1 ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> o_l ( 1 02 ( ) 03 <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 COMP ETED DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNAT E PHONE W/AREA CODE <br /> FOR LOCAL AGENCY US 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 PERMIT IO # <br /> f 1 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br />