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l <br /> STATE ID NUMBER 00000056885001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( D 03 EPDXY LINING ( H 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN t l 05 NONE <br /> ( P 06 TAR OR ASPHALT t ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( D 05 SUCTION ( ) 06 UNKNOWN ( D 07 NONE <br /> VII LEAK DETECTION <br /> t ) 01 VISUAL (X) 02 STOCK INVENTORY ( D 04 VAPOR SNIFF WELLS ( D 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (X) 07 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 APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASTS (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOCED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ' 01 O02 O03 IIIIIIIIIII <br /> ( l 01 ( D 02 ( ) 03 <br /> t D 01 t ) 02 ( ) 03 <br /> t D 01 ( ) 02 ( ) 03 <br /> ( 101 ( 102 ( ) 03 <br /> ( D Oi ( l 02 ( ) 03 <br /> ( D 01 ( ) 02 ( ) 03 <br /> t ) 01 ( D 02 ( ) 03 i <br /> ( ) 01 ( D 02 ( ) 03 <br /> # CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l 01 YES (X) 02 NO <br /> i <br /> HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. +� <br /> 1 <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE i <br /> I <br /> I <br />=0R LOCAL AGENCY USE ONLY <br /> AOMINISTPATING AGENCY CITY CODE COUNTY CODE <br /> I <br /> i <br /> i <br /> CCNTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 01 YES f ) 02 NO <br /> 5C04-070185 (10/18/85) PAGE 2 <br />