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I# STATE ID NUMBER 00000038917003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINEA ( ) 02 ALKYD LINING i 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( J 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. C 1 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN f ) 05 NONE <br /> (X) 06 TAR OR ASPHALT 4 ) 09 OTHER. <br /> VI PIPING <br /> I <br /> A, ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f D 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION f 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST f ) 09 NONE f 1 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F 1OU APE NOT REQUIRED TO CCMPLE7E THIS SECTION <br /> C'J?F.ENTLY PREVIO'U'SLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COM:'tERCIAL NAME ) <br /> STORED STORED <br /> 1 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> 1 <br /> 01 i 1 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 1 1 03 <br /> ( 1 <br /> 01 ( ) 02 [ 1 03 <br /> ( J 01 ( ) 02 ( ) 03 <br /> ( 1 01 t ) 02 ( ) 03 <br /> r <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02. NO <br /> THIS FORM HAS BEEN CDMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PE <br /> ON FIL1)t6 ( �iNATURE 1 PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN% TRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT IF' SON, PHONE W/A EA CODE <br /> ,/r�� �y <br /> VO <br /> l'A7E OF LAST INSPECTION IN COMPLIANCE REKNIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES, ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />