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CONTAINER CONSTRUCTION STATE ID NUMBER 00000058305001 <br /> F_( <br /> BBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING i J 04 PHENOLIC LINING ( 1 OS GLASS LINING <br /> UNLINED (X) 08 UNKNOWN ( ) 09 OTHER:LYETHCENE WRAP ( ) 02 VINYL WRAPPING ( J 03 CATHODIC PROTECTION iX) 04 UNKNOWN ( 1 05 NONE <br /> TAR OR ASPHALT ( J 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( l 01 DOUBLE-WALLED PIPE { ] 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( l 05 SUCTION (X) 06 UNKNOWN t J 07 NONE <br /> B. UNDERGROUND PIPING: ( ] 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) { ) 04 PRESSURE [ 1 05 SUCTION ( l Ob UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> i ) 01 VISUAL' ( ! 02 STOCK INVENTORY C l 04 VAPOR SNIFF WELLS { 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS It ] 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> `F YCU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> STORED STOPrO CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( ) 01 { J 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 d 1 03 <br /> { J 01 ( l 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( f 01 ( ) 02 ( 1 03 <br /> 70,1 ( J 02 ( ) 03 LL30 ( 1 02 ( 1 03 <br /> ( ) OZ ( 1 02 { ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 [ 1 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />=CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST CF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) <br /> PHONE WAR <br /> CODE <br /> FOR LOCAL AGENCY USE ONLY <br />--"=N;STRATIN3 AGENCY <br /> CITY CODE COUNTY CODE <br /> CONTACT PERSON <br /> PHONE W/APEA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE <br /> PERMIT APPROVAL DATE TPANSACTICN DATE <br /> ( k dl YES F 1 02 NO LOCAL PERMIT ID # <br /> 5C04-070185 (10/18/85) <br /> PAGE 2 <br />