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STATE ID NUMBER '00000050198001 <br /> CONTAINER CONSTRUCTION <br /> Et ) <br /> RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 07 UNLINED (X) 08 UNKNOWN f 1 09 OTHER: <br /> POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> 06 TAR OR ASPHALT ( ) 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 ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 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 OAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> (X) 01 ( ) 02 ( ) 03 WASTE WATER (PROCESS OR INDUSTRIAL) <br /> ( 1 01 f 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> [ l <br /> 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 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 FILIN3 (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATIN3 AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT :0 # <br /> ( ) O1 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />