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STATE ID NUMBER 00000065248003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED t ) 02 ALKYD LINING 03 EPDXY LINING t ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> { ) 07 UNLINED t ) 08 UNKNOWN (X) 09 OTHER: RESIN-EPDXY <br /> F. ( ) 01 POLYETHLENE WRAP i ) 02 VINYL WRAPPING t l 03 CATHODIC PROTECTION t ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT t ) 09 OTHER: <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 ( ) 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 ( ) 05 SUCTION ( ) 06 UNKNOWNi ) 07 NONE <br /> VII LEAK DETECTION <br /> t ) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS (X) 05 SENSOR INSTRUMENT <br /> (X) 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 ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( l 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t ) <br /> 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) t13 <br /> t J 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> t l 01 ( ) 02 ( ) 03 <br /> t ) <br /> 01 O 02 ( f 03 <br /> i ) <br /> 01 ( ) 02 ( 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAIN R LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES (X) 02 NO <br /> THIS FORM H ,BEEN COMPLETED' ER THE PENALTY OF PERJURY A # TO THE BEST OF MY K LEDGES IS TRUE CORRECT. <br /> PERSON FI ( ATURE) PHONE W/ARE CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINI :RATING A ENCY ^ r CITY CODE COUNTY CODE <br /> CONITAC ,PER ON PHONE W/AR:EA CODE <br /> LT01, <br /> EO LAST SPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( D 01 YES t ) 02 NO <br /> HSC04-070185 (05/05/86) PAGE 2 <br />