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STATE ID NUMBER 00000009092002 <br /> / <br /> CONTAINER CONSTRUCTION <br /> E. l ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 104 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED IX) 08 UNKNOWN t ) 09 OTHER! <br /> F. ( 1 01 POLYETHLENE WRAP 1 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION 1X1 04 UNKNOWN 1 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT l 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING! ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING! ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( l 06 UNKNOWN 1 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY l 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f 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 /> CURPENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (D0 NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> 1 ) <br /> 01 ( ) 02 ( ) 03 <br /> l l Ol f 102 ( ) 03 <br /> ( ) Ol f 1 02 ( ) 03 <br /> ( ) Ol ( 1 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( ) Ol f 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br /> 1 ) 01 ( ) 02 ( 1 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 FIIING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ACMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/APEA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 1 1 01 YES ( ( 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />