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STATE ID NUMBER 00000002205003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F.. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> [A. ABOVEGROUND PIPING: ( D 01 DOUBLE-WALLED PIPE t 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> } ('CHECK APPROPRIATE BOX(ES) ( ,1 04 PRESSURE ( ) 05 SUCTION t l 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING t ) 01 DOUBLE-WALLED PIPE ( T 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE t ) 05 SUCTION E 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK 'DETECTION <br /> E 3 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS { ) 05 SENSOR INSTRUMENT <br /> 06 GROUND WATER MONITORING WELLS ( } 07 PRESSURE TEST -(X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDE>RGROUNO CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# -(IP' KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 t ) 03 <br /> ( 1 '01 ( l '02 ( l 03 <br /> f ) 01 ( ) 02 ( } 03 <br /> t ) 01 ( i 02 t J 03 <br /> ( } 01 ( ) 02 f D 03 <br /> } 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( } 03 <br /> ) 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> t ) 01 (' ) 02 ( ) 03' <br /> *'CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? .f J 01 YES (X) 02 NO <br /> THIS FORM.NAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEP. ING (01 "A U ) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTIONIN COMPLIANCE PERMIT APPROVAL DATE. TRANSACTION DATE- LOCAL PERMIT ID # <br /> i } 01 YES C ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />