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CONTAINER CONSTRUCTION STATE ID NUMBER 00000059193001 <br /> EEBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( } 05 GLASS LINING <br /> UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> LYETHLENE WRAP f ) 02 VINYL WRAPPING ( } 03 CATHODIC PROTECTION (X) 04 UNKNOWN i ) 05 NONE <br /> TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( i 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( i 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE I ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION { ) 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> =) 06 <br /> AL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( i 05 SENSOR INSTRUMENT <br /> OUND WATER MONITORING WELLS WH 07 PRESSURE TEST ( ) 09 NONE ( i 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 L'CMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS« (IF KNOWN) <br /> CHEMICAL (00 NOT USE OOMMERCIAL NAME) <br /> STO=ED STOPED <br /> 01 ( ) 02 ( ) 03 1 11 <br /> ( ) <br /> 01 ( ) 02 ( i 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> [ ) 01 ( i 02 ( ) 03 -- <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f i <br /> 01 f } 02 f l 03 <br /> ( ) <br /> 01 ( i 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FISCONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPL D UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> FERSCN LN E) <br /> [P�KON;ffW/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 tAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( ) O1 YES ( ) 02 NO LOCAL PERMIT ID #t <br /> SC04-070185 (10/18/85) <br /> PAGE 2 <br />