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�. �. <br /> STATE ID NUMBER 00000064217002 <br /> CONTAINER CONSTRUCTION <br /> E. 1 ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) OS GLASS LINING <br /> 1 ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION 1X1 04 UNKNOWN ( 1 OS NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN l ) 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 <br /> 01 VISUAL (X) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 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 /> CL)RRENTLY PREVIOUSLY DELETE CAS# IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL HAMEI <br /> STOP!D STORED <br /> i ) O1 ( ) 02 ( ) 03 <br /> 1 l <br /> 01 ( ) 02 ( ) 03 <br /> 1 ) <br /> 01 ( ) 02 ( I 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 l ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> 1 l 01 ( ) 02 ( ) 03 <br /> 1 ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> P 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 AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE ) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY C00! <br /> CONTACT PERSON PHONE W/AREA COD! <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DAT! TRANSACTION DATE (DIAL PERMIT ID 4 <br /> 1 ) O1 YES 1 ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />