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STATE ID NUMBER 00000006224003 <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t l 04 PHENOLIC LINING t ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION t ) 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT "f l 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( 3 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: [ l 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) tX) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL (X) 02 STOCK INVENTORY (X) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING )YELLS 07 PRESSURE TEST t ) 09 NONE ( 3 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU ARE NOT REyUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IP KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />( D 01 <br />( ) 02 <br />(`) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />E ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />C ) 01 <br />( ) 02 <br />( ) 03 <br />f ) 01 <br />( ) 02 <br />( ) -03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ,) 02 <br />( ) 03 <br />E ) O1 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t l 01 YES (X)-02 NO <br />THIS FORJ HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSO ILI IGNATURE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMI'RATIN^a <br />AGENCY <br />CITY CODE <br />COUNTY CODE <br />CONTACT PERSON <br />AJPHONE <br />W///ARE�A CODE <br />DATE OF AST INSPECTION <br />IN COMPLIANCE <br />PERMIT <br />APPROVAL DATE <br />TRANSACTION DATE <br />LOCAL PERMIT IO # <br />G <br />( ) 01 YES J 02 NO <br />