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CONTAINER CONSTRUCTION STATE ID NUMBER 00000065391006 <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING [ ) 03 EPDXY LINING ( D 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP l ) 02 VINYL WRAPPING { 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER. <br /> VI PIPING <br /> A. ABOVEGROUNO PIPING: ( ) 01 DOUBLE—WALLED PIPE d ) 02 CONCRETE—LINED TRENCH d ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( ) 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 CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> p1 f 1 02 ( 1 03 t +� <br /> ( ) 01 d 1 02 ( ) 03 f 5 c <br /> ( ) Ol ( 1 02 ( 1 03 <br /> ( ) <br /> 01 ( 1 02 ( 1 03 <br /> 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( i <br /> 01 ( ) 02 ( ) 03 <br /> ( D 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 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 /> PERSO FI G ( N .URE)C t_1 PHONE 406APEA C E <br /> --C <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING A NCY CITY CODE COUNTY CODE <br /> t L15T �C7 <br /> CONTAC ERSON PHONE W/AREA CODE <br /> OIL, O UPJ <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> I ) 01 YES I ) 02 NO <br /> HSC04-070185 (05/05/86) PAGE 2 <br />