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STATE ID NUMBER 00000014048002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING 1 ) 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> f ) 06 TAR OR ASPHALT ( 109 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 ( 1 05 SUCTION f 1 06 UNKNOWN ( ) 07 NONE <br /> S. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION 1 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> f 1 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF )OU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPRENTLY PPEVICUSLY DELETE CASK (IF KNOWN) <br /> STORED STORED CHEMICAL (DO NOT USE COMMlRCIAL NAME) <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f 101 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 ( 1 03 <br /> 1 ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> l l 01 1 ) 02 ( 1 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 /> IS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> EPSON FILING (SIGNATURE ) PHONE W/APER CODE <br /> OR LOCAL AGENCY USE ONLY <br /> DMINISTPATING AGENCY CITY CODE COUNTY CODE <br /> ONTACT PERSON <br /> PHONE W/AREA CODE <br /> ATE OF LAST CNSPECTiON IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO R <br /> I 1 01 YES I 1 OE NO <br /> C04-070185 (10/18/85) i <br /> . . PAGE 2 <br />