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CONTAINER CONSTRUCTION STATE ID NUMBER 00000054749006 <br /> E) Ol <br /> BER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING 1 1 05 GLASS LINING <br /> UNLINED (X) 08 UNKNOWN l ) 09 OTHER: <br /> YETHLENE WRAP ( ) 02 VINYL WRAPPING l 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> AR OR ASPHALT f l 09 OTHER: <br /> VI PIPING <br /> EABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> K APPROPRIATE BOX ES) ( ) C4 PRESSURE 1 1 05 SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> GROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> K APPROPRIATE BOX(ES) 1 1 04 PRESSURE 1X1 05 SUCTION l 1 06 UNKNOWN l 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL ( ) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS f l 05 SENSOR INSTRUMENT <br /> f ) 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-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN( <br /> STOPED STORED CHEMICAL (DO NOT USE COMMCRCIAL NAME ) <br /> ( 1 Ol I 1 02 ( ) 03 <br /> l ) 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 1 ) 02 ( 1 03 <br /> f l O1 ( 1 02 ( 1 03 <br /> ( 1 <br /> 01 ( 1 02 1 1 03 <br /> f ) <br /> 01 ( ) 02 f 1 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( 1 03 <br /> ( l <br /> 01 1 ) 02 ( 1 03 <br /> ( ) <br /> 01 l 1 02 f ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f 1 101 YES (X) 02 NO <br /> THIS FORM HAS BEEN COM TED THE PENALTY PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATU / PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE <br /> couNrr cone <br /> CONTACT PERSON <br /> PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DAT[ TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 Ol YES f ) 03 NO <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br />