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CONTAINER CONSTRUCTION STATE ID NUMBER 00000066457003 <br /> E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> F. 1 ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X1 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH I 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. IRIDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 107 NONE <br /> VII LEAK DETECTION <br /> t ) 01 VISUAL ( ) 02 STOCK INVENTORY 1 ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE I ) 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 (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 t 102 ( 1 03 <br /> ( ) 01 ( ) 02 t ) 03 <br /> [ ) 01 ( ) 02 ( ) 03 <br /> ( 1 O1 1 ) 02 1 1 03 <br /> t 1 O1 f ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 111 t ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION GATE LOCAL PERMIT ID # <br /> ( ) 01 YES f ) 02 NO <br /> HSC04-070185 (08/29/86) PAGE 2 <br />