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STATE ID NUMBER 00000018304005 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( } 03 EPDXY LINING € } 04 PHENOLIC LINING f i 05 GLASS LINING <br /> (X) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: <br /> IF i } 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( } 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( D 05 NONE <br /> (X) D6 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING ( ) 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( l 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLEO PIPE [ 1 02 CONCRETE—LINED TRENCH (X) 03 GRAVITY ' <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN l ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( } 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER= <br /> L <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REgUIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STC?ED STORED <br /> ( r 01 ( ) 02 ( 1 03 <br /> c 1 01 c 1 u ( ) a3 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( } 03 <br /> ( } 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> al ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( l 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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 ANO CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/ARE.A CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTP.ATING AGENCY CITY CODE COUNTY CODE <br /> COr9TACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTIDN DATE LOCAL PERMIT ID # <br /> ( ) 01 YES 1 a 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />