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CONTAINER CONSTRUCTION STATE ID NUMBER 00000020411002 <br /> EF <br /> 01 RUBBER LINED f ) 02 ALKYD LINING ( r 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> X) 07 UNLINED f J 08 UNKNOWN f r 09 OTHER: <br /> 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING 4 ) 03 CATHODIC PROTECTION ( r Q4 UNKNOWN [X1 OS NONE <br /> 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEN <br /> D PIPING: ( ) 01 DOUBLE-WALLED PIPE C 1 02 CONCRETE-LINED TRENCH i l 03 GRAVITY <br /> (CHEPROPRIATE BOXES) ( ) 04 PRESSURE ( 1 0'5 SUCTION ( l 06 UNKNOWN ( r 07 NONE <br /> B. UNDEND PIPING: O1 DOUBLE-WALLED PIPE [ ) 02 CONCRETE-LINED TRENCH i ) Q3 GRAVITY <br /> CCHEPROPRIATE BOX ES) (X) 04 PRESSURE [ 1 05 SUCTION ( ) 06 UNKNOWN i ) 07 NONE <br /> VII LEAK DETECTION <br /> =) 06 <br /> AL � 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> OUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST W 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CH-=CF:ED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> CTORED STOPED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( ) 01 ( ) 02 ( r 03 <br /> f 1 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( J 01 C ) 02 ( ) 03 <br /> 1 J OI C ) 02 ( r 03 <br /> C 1 01 ( ) 02 C ) 03 <br /> i 1 01 ( ) 02 ( ) 03 <br /> l 01 ( ) 02 ( ) 03 <br /> ( 1 01 f ) 02 ( ) 03 <br /> 1 01 f 1 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? C ) 01 YES (X) 02 NO <br /> HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> R`R N FILINC.7 1G UR <br /> PONE W/AREA CODE <br />:OR LOCAL AGENCY USE ONLY 6 <br />(OMINISTRATING A NCY <br /> ' CITY CODE COUNTY CODE <br />;CNTACT PEPSON <br /> R !AREA CODE <br /> ATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( 1 01 YES ( ) 02 NO LOCAL PERMIT IO # <br /> C04-070185 (10/18/85) <br /> PAGE 2 <br />