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STATE ID NUMBER 00000068166001 <br /> CONTAINER CONSTRUCTION <br /> E. [ l 01 RUBBER LINED t ) 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING I ) 05 GLASS LINING <br /> t ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. I ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( I 01 DOUBLE-WALLED PIPE [ l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN I 1 07 NONE <br /> VII LEAK DETECTION <br /> ( l <br /> 01 VISUAL ( ) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS l ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS I ) 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 /> ( 1 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 I I <br /> ( I <br /> 01 ( ) 02 ( ] 03 <br /> ( 1 O1 ( ) 02 ( 103 <br /> ( 1 <br /> 01 ( 1 02 t ) 03 <br /> I 1 01 ( ) 02 ( 1 03 <br /> ( 1 Ol ( 1 02 ( ) 03 <br /> I ) Ol ( ) 02 t 103 <br /> ( I Ol ( ) 02 ( 1 03 <br /> ( ) 01 t ) 02 t 103 <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 CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES f ) 02 NO <br /> • HSC04-070185 (07/03/87) PAGE 2 <br /> *moll <br />