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� M <br /> CONTAINER CONSTRUCTION STATE ID NUMBER 00000037391003 <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED f ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ] 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> [ 1 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS ( 1 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASR (IF KNOWN) <br /> STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( ) 01 [ ) 02 ( ) 03 <br /> f ) O1 ( ) 02 f l 03 <br /> ( 1 01 f ) 02 ( ) 03 <br /> ( 1 Ol ( 1 02 I 1 03 <br /> [ ) Ol ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( l Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> C ) 01 ( 1 02 ( ) 03 <br /> ( ) Ol ( ) 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-ANTO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) <br /> PHONE W/AREA ODE <br /> FOR LOCAL AGENCY USSk-_ Y <br /> ADMIcNI-STR�ATINGG AGENCY <br /> c. (� CI T�Co E COUNTY CODE <br /> CONTACT PERSON 'liJUl ��ll/Y <br /> �S PHONE W��Ep ODE ^ <br /> DATE OF L ST INSPECTION IN CO LIANCE PERMIT APPROVAL DATE TRANSACTION DATE ✓SGJ <br /> ( l O1 YES [ ) 02 NO LOCAL PERMIT ID # <br /> ISC04-070185 (10/18/85) <br /> PAGE 2 <br /> A <br />