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�.r <br /> CONTAINER ..i <br /> CONSTRUCTION STATE ID NUMBER 00000004169010 <br /> E• ( 1 O) 07 UNLINED ( 1 08 URUBBER LINED ( ) 02 ALKYD LINING <br /> (X) ( ) 03 EPDXY LINING ( ) 04 PHENOL <br /> NKNOWN 09 OTHER: <br /> IC LINZNG ( ) 05 GLASS LINING <br /> ( ) <br /> F• ( 1 <br /> 01 HLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWNf ) 05 NONE <br /> 06 TAR <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED <br /> DPIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> !CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUNO PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) OS SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (Xl 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS CA"7 PRESSURE TEST ( ) 09 NONE O OTHER: <br /> r <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) <br /> STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> (X) 01 ( ) 02 ( ) 03 be I I MOTOR OIL <br /> f ) 01 ( ) 02 ( 1 03 I I I <br /> f l Ol f ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> t ) 01 f l 02 ( ) 03 <br /> ( 1 Ol f ) 02 f ) 03 <br /> ( ) Ol ( ) OR ( ) 03 <br /> i 103 ( 1 02 ( ) 03 <br /> f 1 <br /> 01 [ ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f 101 YES (X) 02 NO <br /> HIS FORM HAS BEEN COMPLETED DER THE PENALTY F PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATOR PHONE W/ARE C00! <br /> FOR LOCAL AGENCY USE ONLY <br /> AD�INISTRATING AGENCY CITY CODE COUNTY COD[ <br /> CONTACT PERSON PH N[ W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DAT[ TRANSACTION DAT[ LOCAL P[WMIT ID A <br /> ( ) O1 YES ( ) 02 NO <br /> ISC04-070185 (10/18/85) PAGE 2 <br />