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CONTAINER CONSTRUCTION <br /> a <br /> O1 RUBBER LINED STATE ID NUMBER <br /> ( 7 02 ALKYD 00000060095001 <br /> (X) 07 UNLINED ( ) 08 UNKNOWN LINING <br /> ( ) 09 OTHERS EPDXY LINING ( ) 04 PHENOLIC <br /> F. ( 7 O1 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING LINING <br /> ( 1 05 GLASS LINING <br /> ( 7 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN <br /> VI PIPING ( ) 05 NONE <br /> A. ABOVEGROUND PIPING: <br /> (CHECK APPROPRIATE BOX(ES) ( 7 01 DOUBLE- <br /> ( ) 04 PRESSURE LEO PIPE ( ) 02 CONCRETE- <br /> B• UNDERGROUND PIPING: ( 7 05 SUCTION LINED TRENCH <br /> (CHECK APPROPRIATE SOX(ES) ( ) 06 UNKNOWN ( 7 03 GRAVITY <br /> ( 7 O1 DOUBES_URE ( PIPE ( ) 07 NONE <br /> ( ) 04 PRESSURE ( ) 02 CONCRETE- <br /> ( 1 05 SUCTION LINED TRENCH <br /> V I I LEAK DETECTION (X) 03 GRAVITY <br /> O 06 UNKNOWN O 07 NONE <br /> ( () 0106VISUAL <br /> GROUNDWATER 02 STOCK INVENTONG RY <br /> (( 7 04 VAPOR SNIFF WELLS <br /> 7 07 PRESSURE TEST ( 7 05 SENSOR INSTRUMENT <br /> MONIT (X7 09 NONE <br /> VIII CHEMICAL COM ( ) 10 OTHER: <br /> POSITION OF <br /> A <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT R qU RED TO C MPLET O RED IN UNDERGROUND <br /> E THIS <br /> CURRENTLY PREVIO'JSIY DELETE CAS# !IF KNOWN( <br /> SECTION CONTAINERS <br /> STOREO STOPED CHEMICAL (DO <br /> NOT USE COMMERCIgL NAME( <br /> ( 1 01 ( 7 02 ( ) 03 <br /> ( l 01 ( ) 02 ( 1 03 <br /> ( 7 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol [ ) 02 ( ) 03 <br /> ( ) Ol ( 1 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 [ ) 03 <br /> + CHECK STATE BOARD CHEMICAL CODE LISTINOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL F, ( ) 01 YES (X) 02 NO <br />'HIS FORM HAS BEEN COMPLETED UNDER THE PEN OF PERJURY AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) <br /> PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY <br /> CITY CODE <br /> COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE <br /> ( 1 01 YES ( ) TRANSACTION DATE <br /> LOCAL PERMIT i0 # <br /> ISC04-070185 110/18/85) <br /> ' PAGE 2 <br />