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STATE ID NUMBER 00000064217005 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING l 1 04 PHENOLIC LINING 1 1 OS GLASS LINING <br /> 1 ) 07 UNLINED (X) 00 UNKNOWN ( ) 09 OTHER: <br /> F. l 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 1 103 GRAVITY <br /> (CHECK APPROPRIATE BOXIESI ( ) 04 PRESSURE ( ) 05 SUCTION 1 ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE (X) OS SUCTION t 1 06 UNKNOWN l 1 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS t ) 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-P YOU ARC NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASS IIP KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> I l O1 1 1 02 l l 03 <br /> ( ) Ol 1 1 02 1 t ) 03 <br /> l ) <br /> 01 ( ) 02 ( ) 03 <br /> ( l <br /> 01 f ) OE ( ) 03 <br /> ( 1 01 t ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 0E ( ) 03 <br /> I ) <br /> 01 ( ) 02 f 1 03 <br /> l ) O1 ( ) 02 ( 1 03 <br /> f 1 Ol ( ) 02 ( 1 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES IX) 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 PILING (SIGNATURE ) PHONE W/AREA COOL <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COVNTY CODE <br /> CONTACT PERSON PHONE W/ARCA CODE <br /> DATE OF LAST INSPECTION INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID R <br /> ( ) O1 YES 1 ) OC NO <br /> H5CO4-070185 (10/18/85) PAGE 2 <br />