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CONTAINER CONSTRUCTION STATE ID NUMBER 00000004169007 <br /> FF. ( <br /> 01 RUBBER LINED ( ) 02 ALKYO LINING f 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LIMING <br /> 07 UNLINED fX) 08 UNKNOWN09 OTHER: <br /> 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ) 05 NONE <br /> l 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( 1 03 GRAVITY <br /> ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH fX) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL 0-L92 STOCK INVENTORY l 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUNd-WATER MONITORING WELLS fy(!'07 PRESSURE TEST �9 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 (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( l <br /> 01 f ) 02 ( ) 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( 1 01 ! ) 02 ! ) 03 <br /> l ) 01 l ) 02 ( 1 03 <br /> ( 1 01 f ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> f ) 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 H BEEN COMPLETED THE PENALTY OF PERJURY AND, TO THE BEST OF KNOWLEDGE, IS TRUE AND CORRECT. <br /> FR; <br /> N NO (SIONATURC X ARE C DE p <br /> LOCAL AGENCY USE ONLY <br /> PDMINI ST P.ATINOAOE NCY CITY CODE COUNTY CODE <br /> �9 <br /> CONTACT PERSONPXO E W:AWEA COOS <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES 1 ) 02 NO <br /> KSC04-070185 (10/18/85) PAGE 2 <br />