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STATE ID NUMBER 00000007116003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER-' <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED IPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE f� 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIES) ( 1 04 PRESSURE 04 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 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 ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPPINTLY PREVIOUSLY DELETE CAS# (If KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 1 I Ol ( ) 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> f 1 Ol ( 1 02 ( ) 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 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 /> �1 <br /> THIS FORM HAS BEEN COMPLETED UNDE 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 CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLZANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> f ) <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />