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1-01 STATE ID NUMBER 00000066435002 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING l ) 03 EPDXY LINING ( l 04 PHENOLIC LINING l l 05 GLASS LINING <br /> (X) 07 UNLINED t ) 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP l ) 02 VINYL WRAPPING l l 03 CATHODIC PROTECTION 1 ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. (CHECKRAPPPRROPRIAPIPING- <br /> BOX(ES) ( l 0104 PRESSURELE( )1PE 02 05 SUCTION CON) 006EUNKNOWN Imo) 07NONE <br /> GRAVITY <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) l 1 04 PRESSURE f ] 05 SUCTION ( 1 06 UNKNOWN l ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY l ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> l ) 06 GROUND WATER MONITORING WELLS ( 1 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( ) Ol ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> C 3 Ol f ) 02 f ) 03 <br /> ( 1 Ol l ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> 1 1 <br /> al ( 7 02 t ) 03 <br /> 1 ) O1 ( 7 02 ( ) 03 <br /> ( 1 <br /> 01 t ) 02 ( ) 03 <br /> f 101 ( 1 02 ( ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? (X) 01 YES ( ) 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 CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) O1 YES ( ) 02 NO <br /> • MSC04-070185 (08/29/86) PAGE 2 <br />