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r <br /> STATE ID NUMBER 00000062887002 <br /> CONTAINER CONSTRUCTION <br /> E. [ ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> f ) 06 TAR OR ASPHALT ( J 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 OOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN (SCJ 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) �4.04 PRESSURE [ ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VTSUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (gid 07 PRESSURE TEST ( ) 09 NONE (7-) 10 OTHER. �,�y�� �- <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YCU ARE NOT RECUI.PED TO COMPLETE THIS SECTION <br /> CUPRENTLY PPEVIOUSLY DELETE CAS# (IF KNCWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STCREC <br /> ( r 01 ( l 02 ( ) 03 <br /> ( r 01 ( l 02 ( l 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( l 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 1_13 <br /> ( l 01 f ) 02 ( J 03 <br /> i ) 01 ( ) 02 ( l 03 <br /> ( 1 01 ( l 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> =CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM M BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> �PERSON F L2 '3 (SIGF.`ATU ) PH NE WfAREA C DE <br /> km tL-CL, � 1 ? -7 ' <br /> FOR LO AL AGENCY USE ONLY <br /> ADMIN:STRAT:NaA 3ENCY f CITY CODE COUNTY CCDE <br /> T Loco- 1 <br /> CCNTACT PERSON PHONE W/AREA CODE <br /> h kN 5 - - 5-2- <br /> DATE <br /> ZDATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> %- ( ) 01YES ( ) 02 NO <br /> 'iSC04-070185 (10/18/85) /' PAGE 2 <br />