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STATE ID NUMBER 00000061629002 <br /> ' CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING l ) 03 EPDXY LINING f 1 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) OB UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING f l 03 CATHODIC PROTECTION 1X1 04 UNKNOWN ( 1 05 NONE <br /> t ) 06 TAR OR ASPHALT l ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) Ol DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN t ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 0 <br /> 1 DOUBLE-WALLED IPE f 1 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST l 1 04 PRESSURE 1 0 <br /> 3 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> .1 I 01 VISUAL ( ) 02 STOCK INVENTORY l ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS l 1 07 PRESSURE TEST (X) 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 /> CURRENTLY PREVIOUSLY DELETE CASR (IF KNOWN) CHEMICAL 100 NOT US! COMMERCIAL NAME ) <br /> STORED STORED <br /> O 01 O 02 1 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> 1 ) Ol l 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) Ol l ) 02 ( ) 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( i 02 ( 1 03 <br /> ( ) <br /> 01 l ) 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 AND CORRECT. <br /> PERSON PILING (SIGNATURE) PHONE W/ARCA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY COD! COUNTY COD[ <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE Of LAST INSPlCTSON IN COMPLIANCE PERMIT APPROVAL DAT[ TRANSACTION DATE LOCAL PERMIT ID ■ <br /> ( ) 01 YES ( 1 OE NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />