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STATE ID NUMBER 0[•0000234,$6001 <br /> CONTAINER CONSTRUCTION <br /> E. 1 01 RUBBER, LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f 1 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> t ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> i <br /> F. ( 1 O1 POLYETHLENE WRAP ( l 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION fXl 04 UNKNOWN ( l 45 NONE <br /> ( ) 06 TAR OR ASPHALT { ) 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLEO PIPE ( 1 02 CONCRETE-LINED TRENCH [ ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION [ 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING ( l O1 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESl (Xl Q4 PRESSURE f l 05 SUCTION ( 1 Ob UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( l 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS t l 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( 1 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 PPEVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ' <br /> STORED STOPED <br /> ( 1 O1 ( 1 02 ( 1 03 - <br /> ( ) 01 ( 1 02 t ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( l 02 [ 1 03 lL_ <br /> E ] <br /> 01 l l 02 ( ) 03 1�1 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 O1 t ) 02 ( 1 03 <br /> t 101 ( 1 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> tlS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> TEIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND) TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> (i,E.'yON FI ING S - ) PHONE W/AREA CODE <br /> r Z( <br /> OR OCAL AGENCY USE ONLY <br /> r..;MINISTPATING AGENCY CITY CODE COUNTY CODE <br /> C.NTACT PERSON PHONE W/AREA CODE <br /> DA.',c OF LAST INSPECTION IN COMPLIANCE PERMIT .APPROVAL DATE TRANSACTION DATE LOCAL PEFMIT ID # <br /> f ) 01 YES t ) 02 NO <br /> PAGE 2 <br /> 04-070185 (10/18/85) <br />