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r.. 'No, <br /> CONTAINER CONSTRUCTION STATE ID NUMBER 00000019366002 <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING <br /> IXl 07 UNLINED ( ) OB UNKNOWN f ) 09 OTHER: ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ] 03 CATHODIC PROTECTION <br /> ) 09 OTHER: [X1 04 UNKNOWN ( 7 OS NONE <br /> ( ) 06 TAR OR ASPHALT ( <br /> VI PIPING <br /> A. ABOVEGROUND PIPING; ( ) O1 <br /> (CHECK APPROPRIATE BOX(E9) DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( 7 03 GRAVITY J <br /> ( ) 04 PRESSURE ( 1 05 SUCTION ( ] 06 UNKNOWN ( ) 07 NONE <br /> i <br /> B. UNDERGROUND PIPING: ( ) <br /> (CHECK APPROPRIATE BOX(ES) ( O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ' <br /> ) 04 PRESSURE (X) 05 SUCTION ( ] 06 UNKNOWN ( ) 07 N] 03 GRAVITY VITY <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL (X) 02 STOCK INVENTORY f ] 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> 1 ) 06 GROUND WATER MONITORING WELLS ( ] 07 PRESSURE TEST f ) 09 NONE f ) 10 OTHER: <br /> VIII CHEMICAL <br /> IF YOU CHECKED COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> STORED STORED CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> ( ] O1 ( ) 02 ( ] 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol f ) 02 ( ) 03 <br /> ( ] 01 ( 1 02 ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 f ) 03 <br /> f 7 01 ( ) 02 ( ] 03 <br /> ( ) O1 1 ) 02 ( ) 03 <br /> ( 1 01 ( 7 02 ( ) 03 <br /> 1 ) 01 ( 1 02 ( ) 03 <br /> f l O1 ( ) 02 f ) 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 FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON TO" <br /> W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 20 # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> \ter �� <br />