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STATE ID NUMBER 00000007404001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING E 1 03 EPDXY LINING [ ) 04 PHENOLIC LINING t 1 05 GLASS LINING <br /> ( 1 07 UNLINED (X) 08 UNKNOWN C ) 09 OTHER: <br /> F. ( ) 01 POLYETHL€NE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 HCNE <br /> ( } 06 TAR OR ASPHALT ( } 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE i ) 02 CONCRETE-LINED TRENCH t } 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING° ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN i 1 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( J 04 VAPOR SNIFF WELLS t ) 05 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 REGUIRED TO COMPLETE THIS SECTION <br /> CUPP=NTLY PREVIOUSLY DELETE CAS# (IF KNCWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STC;ED STCPED <br /> t 1 01 ( 1 02 ( ) 03 <br /> ( ) al ( ) 02 ( ) 03 <br /> ( } 01 ( ) 02 i ) 03 <br /> ( ) 01 ( 1 02 [ 1 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> l 01 ( 1 02 ( 1 03 <br /> c 0 ( ' 02 t ) 0311111 1 1 1 1 1 1 IL <br /> ( ' 01 ( ' 02 t ) 031111111111111 <br /> ( 1 01 ( 1 02 C ) 03 <br /> [ ) 01 ( 1 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? C l 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 IN COMPLIANCE �ITROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( 1 02 NO <br /> H3C04--070155 (10/18/85) PAGE 2 <br />