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0 0 <br /> STATE ID NUMBER 00000065270003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING t ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> ( ) 07 UNLINED ( ) 08 UNKNOWN (X) 109 OTHER: RESIN-EPDXY <br /> F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE t D 05 SUCTIONt ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> t ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS (X) 05 SENSOR INSTRUMENT <br /> (X) 06 GROUND WATER MONITORING WELLS (X) OT PRESSURE TEST ( ) 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 (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t l <br /> 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 t l 03 <br /> ( ) 01 ( ) 02 t ) 03 <br /> ( ) Ol ( ) 02 t ) 03 <br /> t ) 01 ( ) 02 t ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> E ) 01 ( ) 02 ( ) 03 <br /> ( ) 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? ( ) 01 YES (X) 02 NO <br /> THIS FORM HA WBEEN COMPLETED UNDER THE PENALTY OF PERJURY : TO THE BEST OF MY KNOWLEDGEP IS TRUE AND CORRECT. <br /> PERSON FI ES ATURE) PHONE W/AR A CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN STRATI NG AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSOM PHONE W/AR A CODE <br /> le <br /> DATE`OFA INSPECTIONFINK COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> �� ) 01 YES ( ) 02 NO <br /> NSC04-070185 (05/05/86) ��' PAGE 2 <br />