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STATE ID NUMBER 00000011472001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> f ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 7 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f 1 04 UNKNOWN ( 1 05 NONE <br /> (X) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 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) f ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( 7 07 NONE <br /> VII LEAK DETECTION <br /> 9f 7 01 VISUAL f ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE 1 ) 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 /> f 1 01 ( 1 02 ( ) 03 <br /> f l O1 f l 02 ( ) 03 <br /> f 1 <br /> 01 ( 1 02 ( ) 03 <br /> f ) O1 f 1 02 ( ) 03 <br /> ( 1 01 f 1 02 1 ) 03 <br /> ( 1 <br /> al ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 7 03 <br /> ( 1 01 1 1 02 f 1 03 <br /> ( ) 01 ( 1 02 1 1 03 <br /> ( 1 01 f 1 02 1 1 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 /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY C00! <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PCRMIT ID # <br /> ( ) <br /> 01 YES ( 1 07 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />