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CONTAINER CONSTRUCTION STATE ID NUMBER 00000014297002 <br /> E• ( ) 01 RUBBER LINED f ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> �F. f J 01 POLYETHLENE WRAP i l 02 VINYL WRAPPING ( J 03 CATHODIC PROTECTION (X) 04 UNY,NOWN <br /> ( ) 06 TAR OR ASPHALT f ) 09 OTHER: f 1 OS NONE <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH APPROPRIATE BOX(ES) 03 GRAVITY <br /> 05 SUCTION f 1 06 UNKNOWN C J 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) i ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( J 07 NONE <br /> VII LEAK DETECTION <br /> ,t J 11 VISUAL�02 STOCK INVENTORY f 1 04 VAPOR SNIFF 'WELLS ( 105 SENSOR INSTRUMENT <br /> ( 1 06 GROU ER MONITORING WELLS fX) 07 PRESSURE TEST ( ) 09 NONE ( J 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPPENTLY' PPEVIOUSLY DELETE C.ASik (IF KNOWNI <br /> STORED STORED CHEMICAL dD0 NOT USE COMMERCIAL NAME) <br /> C J 01 ( ) 02 ( ) Q3 <br /> f ) 01 ( ) 02 f J 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> ( 7 01 t 1 02 ( J 03 <br /> ( ) 01 ( l 02 ( J 03 <br /> C ) 01 ( ) 02 ( l 03 <br /> f l al ( ) 02 f l 03 <br /> ( ) o1 ( ) 02 ( J 03 <br /> ( ) 01 t ) 02 ( ) 03 <br /> ( 1 01 i ) 02 ( J 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 /> PHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) <br /> FHCNE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY f(C <br /> ADMINISTRATING AGENCY �IS CITY CODE <br /> , 7-A;,I n „iy� `1 „ COUNTY CODE <br /> CONTACT PEPSON <br /> � cI_ PHONE W/AREA CODE <br /> f„( J JJ Zo _ -?0-" S­ Si/ 7 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( ) 01 YES i ) 02 NO LOCAL PERMIT ID # <br /> 5C04-070185 (10/18/85) <br /> PAGE 2 <br />