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0 <br /> STATE ID NUMBER 00000051616002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING t B 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: < <br /> F. ( ) 01 POLYETHLENE WRAP t D 02 VINYL WRAPPING ( d 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVE152OUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSUREt ),05 SUCTION t ) 06 UNKNOWN ( B 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE t ) 02 CONCRETE—LINED TRENCH f a 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIES) ( ) 04 PRESSURE (,X) 05 SUCTION ( ) 06 UNKNOWN t l 07 NONE <br /> VII LEAK DETECTION <br /> 01 <br /> t ) 01 VISUAL (X) 02 STOCK INVENTORY E J 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( a 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER.- <br /> CHEMICAL <br /> THER-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# (I"F KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME), <br /> STORED STORED <br /> ( ?' 01 ( ) 02 t a03 <br /> { ) 01 ( ) 02 t ) 03 <br /> ( ') 01 ( l 02 t ) 03 <br /> ( ) 01 t ) 02 ( ) 03 <br /> ( :} 01 ( a 02 ( ) 03 <br /> B 01 ( ) 02 ( ) 03 <br /> t ) 03 ( J 02 ( D 03 <br /> { ) 01 t # 02 ( ) 03 <br /> f } 01 i d 02 ( ) 03 <br /> ( d 01 E 1 02 ( ) 03 <br /> * <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? i ) 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) P ONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINIST ATING A ENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/A EA CODE <br /> CATE OF LAST INSPECTIONIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 #f <br /> { ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />