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STATE ID NUMBER 00000031631001 <br /> • CONTAINER CONSTRUCTION <br /> E. f 1 01 RUBBER LINED f ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> 07 UNLINED ( ) 08 UNKNOWN ( ] 09 OTHER= <br /> F. f l 01 POLYETHLENE WRAP f l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION -HM 04 UNKNOWN WOr, NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( 7 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN 2alL.HONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION f 1 06 UNKNOWN l 1 07 NONE <br /> VII LEAK DETECTION <br /> ."R'+0_. 1 VI41Id1 4 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f l 05 SENSOR INSTRUMENT <br /> ROUND T NI7ORING WELLS ( ) 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 /> CURRENTLY PREVIOUSLY DELETE OAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> l l 01 ( l 02 ( ) 03 <br /> f ) <br /> 01 f ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 ( 1 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 /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING ( ATUR PHONE W/AREA CODE <br /> u� �l gy5-fr�if <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY �TYCODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> O1 YES ( ) 02 NO <br /> MSC04-070185 (10/18/85) PAGE 2 ; <br /> r, <br /> NNW <br /> I <br />