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CONTAINER CONSTRUCTION STATE ID NUMBER 00000059193003 <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( J 03 EPDXY LINING ( ! 04 PHENOLIC LINING ( ! 05 GLASS LINING <br /> i ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( 106 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING --- <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( 1 04 PRESSURE ( ! 05 SUCTIQN { ) 06 UNKNOWN ( ) 07 NONE <br /> B. (CH UNDERGROUND PIPING: t } 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXCESI (X) 04 PRESSURE C ) 05 SUCTION ( ! 06 UNKNOWN ( ) 07 HONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> { ) 06 GROUND WATER MONITORING WELLS (9-1. 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS <br /> SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASH (IF KNOWN) _ <br /> STORED STOPED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( J 01 t l 0202 t l 03 <br /> ( ) al ( ) ( ) 03 <br /> i ) 01 € ! 02 ( ) a3 <br /> ( ) 01 r ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ! 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> i ) 01 i ) 02 ( ) 03 11 1 <br /> ( ! 01 C ) 02 ( ) 03 <br /> f ) 01 f J 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> kCONTAINER LOCATED ON AN AGRICULTURAL FARM? <br /> ( ) 01 YES CX) 02 NO <br /> CHIS FORM HAS BEEN COMP TED UNDER THE PENALTY OF PERJURY AND, <br /> TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEP 0 F NG SIG E) <br /> PHONE W/AREA CODE <br /> Qom'' 3 --r,� ft <br /> FOR LOCA AGENCY USE ONLY <br /> ADMINISTRATING AGENCY <br /> CITY CODE COUNTY CODE <br />'ON <br /> TACT PERSON <br /> PHONE W/AREA CODE <br /> YATE OF LAST INSPECTION IN COMPLIANCE <br /> PERMIT APPROVAL DATE TRANSACTION DATE <br /> S 1 01 YES i D 02 NO LOCAL PERMIT 10 tt <br />�C04-070185 (10✓18/85) <br /> PAGE 2 <br />