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v <br /> STATE ID NUMBER 00000004122004 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP f ] 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (XI 04 UNKNOWN f ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING( f ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN [ ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL ( ) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> f ] 06 GROUND WATER MONITORING WELLS HC) 07 PRESSURE TEST jZ�L 09 NONE ( l 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 ( l 02 ( ) 03 <br /> f 1 O1 ( ) 02 ( ) 03 <br /> f ) Ol ( l 02 ( 1 03 <br /> f ) <br /> 01 ( 1 02 f 1 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( l 01 f l 02 ( l 03 <br /> t ) Ol f 1 02 f ) 03 <br /> ( 1 Ol t l 02 ( ) 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) Ol YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> PERSON FILING (SIO T RE) PHONE /AREA CODE <br /> FOR LOCAL AGENCY USE 4LY <br /> ADMTZTIrAOE NCY �i CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DAT! TRANSACTION DAT! LOCAL PERMIT ID R <br /> ( ) <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 9 <br />