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STATE ID NUMBER 00000063817001 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED W 02 ALKYD LINING [ ] 03 EPDXY LINING ( 1 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> ( ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. 1 ) Ol POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ] 03 CATHODIC PROTECTION ( 1 04 UNKNOWN l ) 05 NONE <br /> (4 ObTAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING( ( ) 01 DOABLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 1 ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 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 (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> (X) 06 GROUND WATER MONITORING WELLS [ 1 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 APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> (X) O1 ( ) 02 ( ) 03 N6 FUEL OIL <br /> f ) O1 ( ) 02 ( ) 03 <br /> ( ) 01 E ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ] 02 ( 1 03 <br /> f ) Ol ( 1 02 ( 1 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> I5 CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSO4 FIlZNO fSIGNATUREI ( PHONE W/AREA CODE <br /> r <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 IO # <br /> ( ) 01 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> Li � <br />