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CONTAINER CONSTRUCTION STATE ID NUMBER 00000000716006 <br /> E• ( ) <br /> 01 RUBBER LINED <br /> (XI 07 UNLINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f ) 08 UNKNOWN ( ) 09 OTHER: <br /> F• ( ) O1 POLYETHLENE WRAP f ) 02 VINYL WRAPPING [ ) 03 CATHODIC PROTECTION <br /> 09 OTHER: (Xl 04 UNKNOWN ( ) OS NONE <br /> ( ) 06 TAR OR ASPHALT ( ) <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ] 04 PRESSURE ( ] 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 105 SENSOR INSTRUMENT <br /> ( ) 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 CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> f ) 01 ( 1 02 ( ) 03 <br /> ( ) Ol ( 102 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 O1 f ) 02 ( ) 03 <br /> [ ) 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( 1 02 ( ) 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 l ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 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 (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 R <br /> ( ) 01 YES ( 7 02 NO <br /> MSC04-070185 (10/18/85) PAGE 2 <br />