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r <br />CONTAINER CONSTRUCTION <br />STATE ID NUMBER 00000016209001 <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />( ) 07 UNLINED (y) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING i ) 03 CATHODIC PROTECTION) 04 UNKNOWN ( ) 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( � wO1 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHOCK APPROPRIATE BOX(ES) `X, 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: (O1 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( 1 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL ( ) 02 STOCK INVENTORY t l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ( l 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 <br />STORED <br />PREVIOUSLY <br />STOPED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 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 />FHI5 FORM HAS BEEN COMPLETED UNVR THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY <br />CITY CODE <br />COUNTY CODE <br />CONTACT PERSON PHONE W/AREA CODE <br />DATE OF LAST INSPECTION JIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />( ) 01 YES ( ) 02 NO <br />HSC04-070185 (10/18/85) <br />0 <br />0 <br />PAGE 2 <br />