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STATE ID NUMBER 00000045880001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER= <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A (CHECK APPROPRIATE'BOX(ES) ( ( 0104 PRESSURELE( 11PE 02 05 SUCTION C(OXIR 06EUNKNOWNTR( 1H07( 3 GRAVITY <br /> NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 7 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> "{ ( ) 06ISUAL GROUND( ) 02 STOCK INVENTOY WATER MONITORING WELLS (( ))007VPRESSURE APOR FTEST LLSX) (09 NONE05 ENI ) 10INSTRUMENT <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 /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) Ol ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( 1 02 ( 1 03 <br /> f. ) <br /> 01 ( ) 02 ( ] 03 <br /> ( ) al ( 1 02 ( ) 03 <br /> ( J 01 ( l 02 ( 1 03 <br /> ( ) 01 ( l 02 [ ) 03 <br /> ( ) 01 [ 1 02 ( ) 03 <br /> ( ) 01 f 1 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 YES (X7 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 <br /> CITY CODE COUNTY CODE <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 4 <br /> ( ) OS YES ( ) 02 NO <br /> PAGE 2 <br /> H5C04-070185 (10/18/85) <br /> 4 • • <br />