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0 STATE ID NUMBER 00000011538001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 104 UNKNOWN ( 105 NONE <br /> (X) 06 TAR OR ASPHALT ( ). 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING ( I 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) Ol DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN f 7 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 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 REWIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( ) <br /> 01 f ) 02 ( 1 03 <br /> [ ) 01 ( 1 02 ( ) 03 <br /> ( l Ol ( 1 02 f ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) OS ( 1 02 ( 1 03 <br /> ( ) <br /> 01 f 1 02 ( ) 03 <br /> ( ) O1 ( 1 02 ( 1 03 <br /> 02 f ) 03 <br /> ( ) 01 ( 1 02 ( ] 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? l 1 01 YES (X) 02 NO <br /> THIS FORM 5 EEN MPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON IN ( I ATURE) PHONE <br /> W 1 E <br /> FOR LOCAL AGEN4 USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> S�nu cud a� �(S+r( c+ 3 <br /> CONT T PERS O PH Nr <br /> CODE <br /> D �6n � <br /> DATE OF LAST iNSPE ON IN COMPLIANCE PERMIT APPROVAL DATE TION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> • <br /> 0 <br />