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pp'" 0 • <br /> STATE ID NUMBER 0000000226400 <br /> CONTAINER CONSTRUCTION <br /> ( 1 <br /> 01 RUBBER LINED 1 1 02 ALKYD LINING ( l 03 EPDXY LINING 1 ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION I 1 04 UNKNOWN (X) 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> PIPING <br /> ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1 ) 04 PRESSURE l 1 05 SUCTION (XI 06 UNKNOWN ( ) 07 NONE <br /> UNDERGROUND PIPING: ( I 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> I LEAK DETECTION <br /> X) 01 VISUAL ( ) 02 STOCK INVENTORY ( 104 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> II CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECEED YES TO IV-F YOU ARE NOT REQUIPED TO COMPLETE THIS SECTION <br /> PRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> TOPED STOPED <br /> X) 01 ( ) 02 ( ) 03 I I I I I I LUBRICATING OIL <br /> X) 01 O 02 O 03 I I I I I I I I I I I I I SEDIMENT AND SLUDGE <br /> ) 01 ( ) 02 1 ) 03 I <br /> ) 01 ( ) 02 ( ) 03 I <br /> ) 01 ( ) 02 ( ) 13 <br /> ) 01 ( ) 02 I ) 03 I I I <br /> ) 01 ( ) 02 ( ) 03 <br /> ) 01 ( ) 02 1 ) 03 <br /> ) 01 ( ) 02 ( ) 03 <br /> ) 01 ( ) 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> i FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />,SONIING TVIIL\ PHON�f'AREA CODE <br /> R LOCAL AGENCY USE ONLY <br /> iIN/STPATING AGENCY CITY CODE COUNTY CODE <br /> 1TACT PERSON PHONE W/AREA CODE <br /> `- OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 # <br /> f ) 01 YES ( ) 02 NO <br /> '0185 (10/18/857 PAGE 2 <br />