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CONTAINER CONSTRUCTION STATE ID NUMBER 00000027845002 <br /> E <br /> . INED ( l 02 ALKYD LINING ( ) 03 EPDXY LINING f ) 04 PHENOLIC LINING ( ) OS GLASS LININ6 <br /> ED (X) O8 UNKNOWN ( 1 09 OTHER:ENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWNf ) 05 NONE <br /> ASPHALT ( ) 09 OTHER:VI PIP <br /> A. ABOVEGROUND PIPING ( 7 01 OOUBLE-WALLED PIPE 1 ) <br /> (CHECK APPROPRIATE BO02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> BOX(ES) 1 0 <br /> ( 4 PRESSURE f ) OS SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> (CHECK APPROPRIATE BOX[ES) 0 <br /> B. UNDERGROUND PIPING: ( ) O1 DOUBLE-WgLLED PIPE ( ) 02 CONCRETE-LINEO TRENCH ( ) 03 GRAVITY <br /> ( 1 4 PRESSURE fX) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( ) 02 STOCK INVENTORY f 7 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CONTAINERS <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> STORED STORED CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> ( 7 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 f 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 ( 7 02 f ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 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) <br /> PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY <br /> CITY CODE COUNTY CODE <br /> CONTACT PERSON <br /> PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE <br /> ( 7 O1 YES ( 1 02 NO PERMIT APPROVAL DATE TRANSACTION DATE <br /> LOCAL PERMIT ID # <br /> ISC04-070185 (10/18/85) <br /> PAGE 2 <br />