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CONTAINER CONSTRUCTION <br /> STATE ID NUMBER 00000066457001 <br /> E• ( ) 01 RUBBER LINED <br /> 07 UNLINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) (X) 08 UN(NOWN ( ) 09 OTHER: <br /> F• l ) O1 POLYETHLENE WRAP ( ) 02 VINYL 40lA <br /> 06 TAR OR ASPHALT PPING ( ) 03 CATHODIC PROTECTION (X) 04 <br /> f ) ( ) 09 OTHER: <br /> lA•DCNOWW ( ) OS NONE <br /> VI PIPING <br /> ABOVEG <br /> OUND <br /> A• (CHECKRAPPR PIPING: ( ) 01 DOUBLE-WALLED PIPE ! ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> �MU(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. <br /> (CHECK <br /> PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION (CONCRETE-LINED UNjOWTRENCH <br /> 07(NO) <br /> W.03 GRAVITY <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 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 /> [31TOIRED <br /> ENTLY PREVIOUSLY DELETE CASK (IF KNOWN) <br /> STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> 01 ( ) 02 ( ) 03Ol ( 1 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( I <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> t ) 01 ( 1 02 ( 103 <br /> ( ) O1 ( ) 02 ( 1 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 DATE LOCAL PERMIT I0 R <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (08/29/86) PAGE 2 <br />