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t <br /> STATE ID NUMBER 00000062578004 <br /> CONTAINER CONSTR"U"CTION <br /> E. ( D 01 RUBBERLINED ( ) 02 ALKYO LINING ( ) 03 E XY LINING ti ) 04 PHENOLIC LINING ( } 05 GLASS LIVING <br /> (X) 07 UNLINED (' ) 08,UNKNOWNf ) 09 OTHER <br /> F. ( } 01 POLYETHLENE WRAP t D 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( ) ,04 'UNKNOWN t ) 05 NONE <br /> f ) 06 TAR OR ASPHALT t D 09:OTHER; <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIKE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( )'04 PRESSURE ( l 05 SUCTION C ) 06 UNKNOWN t } 07 NONE <br /> B. UNDERGROUND PIPING: t D 01' DOUBLE—WALLED PIPE' ! ) 02 CONCRETE—LINED TRENCH3 GRAVITY <br /> {CHECK APPROPRIATE BOXES) ( } 04 PRESSURE (jV 0.5 SUCTION ( } 06 UNKNOWN ( } 07 E <br /> VII LEAK DETECTION <br /> t ) 01 VISUAL '(X) 02 STOCK INVENTORY ( } 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> 06 GROUND WATER MONITORING WE=LLS QV 07 PRESSURE TEST ( ) 09 NONE f l 10 OTHER. <br /> VIII CHEMICAL COMPOSITTO:N OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU API NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CKEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t D 01 ( 1 0 ( } 03 <br /> t ) 01 ( ) 02 ( } 03 <br /> } 01 ( ) ,02 f ) 03 <br /> E D 01 ( ) 02 { D 03 <br /> C } <br /> 01 ! D 02 ( D 0.3 <br /> ( T 01 ( D 02 ( } 03 <br /> D 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( } 02 t ) 03 <br /> ( ) 01 4 } 02 ( ) 03 <br /> ( } 01 ( D 02 ( DOS <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAI)VER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANDS TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON F 'LI G (SIGNATUREPHONE !AREA CODE <br /> - Q <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON U PHONE W/AREA CODE <br /> UATE OF LAST INSPECT NI COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 2® ( 9 01 YES ( ) 02 NO <br /> MSC04-070185 (10/18/85) a PAGE 2 <br />