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STATE ID NUMBER 00000054749003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X1 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: <br /> F. 1 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN 1X1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 I <br /> 01 VISUAL ( ) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GROUND WATER MONITORING WELLS 1 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) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> (X) 01 1 ) 02 ( ) 03 5 7 5 5 6 I I I I I I I PROPYLENE GLYCOL <br /> ( 1 <br /> 01 1 1 02 1 ) 03 <br /> f l O1 ( 1 02 f 1 03 <br /> f 1 <br /> 01 1 1 02 ( ) 03 <br /> f l Ol ( l 02 f l 03 <br /> 1 l 01 ( 1 02 ( ) 03Ll <br /> ( 1 01 1 I 02 ( 1 03 <br /> f ) <br /> 01 ( 1 02 ( 1 03 <br /> ( ) <br /> 01 1 1 02 ( ) 03 <br /> f ) <br /> 01 ( 1 02 ( 1 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 COMPLE D UNDE THE PENALTY F PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATOR PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ON <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREACODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION PATE LOCAL PERMIT ID # <br /> f > 01 YES ( ) 02 NO <br /> MSC04-070185 (10/18/85) <br /> PAGE 2 <br />