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STATE ID NUMBER 00000065391012 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED t ) 02 ALKYD LINING { 1 03 EPDXY LINING l ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP [ ) 02 VINYL WRAPPING i 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> { ) 06 TAR OR ASPHALT t ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE i ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN { 1 07 NONE <br /> VIZ LEAK DETECTION <br /> (X) 01 VISUAL 1 ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS (X) 05 SENSOR INSTRUMENT <br /> [ ) 06 GROUND WATER MONITORING WELLS [ ] 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 CASA (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) 01 ( ) 02 ( 1 03 1 1.5111-510181 POTASSIUM CYANIDE <br /> (X) 01 ( ) 02 ( ) 03 1114131313191 SODIUM CYANIDE <br /> (X) O1 ( ) 02 ( ) 03 111311101713121 SODIUM HYDROXIDE <br /> (X) 01 ( ) 02 ( ) D3 5 7 1 2 5 1 1 1 1 1 1 1 CYANIDES, INORGANIC SALTS <br /> t ) 01 ( ) 02 ( ) 03 <br /> { ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 f ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( l 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( 1 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 /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEAL,F141N IANA7'�1PHO E W/K RE <br /> A 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 ID # <br /> ( ) 01 YES ( 1 02 NO <br /> HSC04-070185 (05/05/86) PAGE 2 <br />