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F <br /> STATE ID NUMBER 00000000725004 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYO LINING t ) 03 EPDXY LINING { } 04 PHENOLIC LINING t } 05 GLASS LINING <br /> (X} 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER. <br /> F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( D 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> 06 TAR OR ASPHALT ( ) 09 OTHERS <br /> VI PIPING <br /> A. ABOVEGROUND PIPING= t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t ) 05 SUCTION ( ) 06 UNKNOWN ( D 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ') 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN t D 07 NONE <br /> VII LEAK DETECTION <br /> ) ,01 VISUAL ( D 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS { ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS C ) 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 CASs# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) <br /> 01 ( ) 02 ( ) G3 <br /> ( <br /> 01 ( D 02 ( D 03 <br /> 01 ( D 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( .) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( `) 01 ( ) 02 ( ) 03 <br /> t .'') 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t ') 01 ( ) 02 ( ) 03 <br /> ) 01 ( ) 02 ( } 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> =CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) 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 INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( ) 01 YES ( ) 02 N0 <br /> HSG04-070185 (10/18/85) PAGE 2 <br />