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4 a <br /> STATE ID NUMBER 00000010781009 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED [ 7 02 ALKYD LINING ( 1 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f l 07 UNLINED (X) 08 UNKNOWN [ ) 09 OTHER: <br /> F. ( 7 01 POLYETHLENE WRAP ( ! 02 VINYL WRAPPING ( ! 03 CATHODIC PROTECTION (X) 04 UNKNDWN i ) 05 NONE <br /> ( ! 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ] 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( 1 04 PRESSURE f } 05 SUCTION [ 7 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: [ ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE f } 05 SUCTION ( l 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> F��( <br /> 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS [ ) 05 SENSOR INSTRUMENT <br /> 7 06 GROUND WATER MONITORING WELLS ( 7 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 /> CVPPENTLY PPEVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STOPED <br /> f 1 01 ( 7 02 I ) 03 <br /> ( J 01 ( ) 02 ( ) 03 <br /> f ) 01 ( 1 02 ( l 03 <br /> l <br /> 01 ( ) 02 ( ) 03 <br /> 1 01 ( l 02 ( ) 03 <br /> 1 <br /> 01 f ) 02 ( ) 03 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( 02 ( 1_13 <br /> f 1 01 ( ) 02 ( 1 03 <br /> ( l <br /> 01 f l 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FIS 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 LEST OF MY KNOWLEDGE, IS TRUE AND COPRECT. <br /> ;EPSON FILING £SIGN.ATUREI -- -- PHONE W/AREA CCOE _ _ - -- <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING .AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/ARE.A CODE <br /> rE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> T0155 (10/18/851 PAGE 2 <br /> i • <br />