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STATE ID NUMBER 00000063026004 <br /> CONTAINER CONSTRUCTION <br /> E( ) 1 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( 7 05 GLASS LINING <br /> ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> O1 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 7 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE) 06 TAR OR ASPHALT ( 7 09 OTHER: <br /> VI PIPING <br /> ENCH <br /> A ICHECKR APPROPRIATE: <br /> P ROPRIATE.BOX(ES) ( ( 0104 PRESSURELEO PIPE 02) 05 SUCTION CONCRETE-LINED( ) 06UNKNOWNTR f�CT 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> B CHECKR APPROPRIATE•BOX(ES) ( ( 01 40PRESSURELED 0105 SUCTION CONCRETE-LINED 06UNKNOWNTR(>O 071N NE GRAVITY <br /> VII LEAK DETECTION <br /> f ) <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( 7 04 VAPOR SNIFF WELLS l ) O5 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS Pp 07 PRESSURE TEST ( 1 09 NONE f 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 /> ( ) 01 ( 7 02 ( ) 63 <br /> ( 7 O1 ( ) 02 ( ) 03 <br /> ( ) 01 ( 102 ( ) 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> l l 01 f 1 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) <br /> 91 f ) 02 ( ) 03 <br /> l ) 01 ( 7 02 f ) 03 <br /> ( ) <br /> 01 ( ) 02 f 7 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,4 BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON IL NG (SIGNAT PHONE W/AREA CODE ' / <br /> FOR LqTAL AGENCY USE ONLY 3 <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 PIRMIT ID # <br /> • f ) 01 YFS f 1 03 NO <br /> NSC04-070185 (10/18/85) PAGE 2 <br />