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STATE ID NUMBER 00000065391005 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING [ ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( 1 OB UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP C ) 02 VINYL WRAPPING C ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN IX) 05 NONE <br /> ( ) 06 TAR OR ASPHALT C ) 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE t ) 02 CONCRET€-LINED TRENCH i ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) i ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 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 /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS (X1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS I 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER= <br /> VIII CHEMICAL, COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU 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 /> t.11ri 01 ( 1 02 1 ) 03 + / C G! <br /> c ) 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 I ) 03 <br /> [ 1 <br /> 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 01 ( 1 03 <br /> ( 1 01 ( ) 02 t ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> l 1 01 ( ) 02 t 1 03 <br /> ( ) O1 ( ) 02 t ) 03 <br /> ( ) 01 ( ) 02 t 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X1 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 /> PERSO .ILIh RSI N URE) PHONE /AREA CODE <br /> ` <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PE ON PHONE W!Al7EA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE REKNIT APPROVAL OATS TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES { ) 02 NO <br /> HSC04-0701135 (05/05/86) PAGE 2 <br />