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STATE ID NUMBER 00000013166003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( i 03 EPn,,Y LINING ( 1 04 PHENOLIC LINING E 1 05 GLASS LINING <br /> (X) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN (X) 05 NONE <br /> { ) 06 TAR OR ASPHALT { 1 09 OThER: <br /> VI PIPING <br /> A. ABOVEGROUND HIPING: ( 1 01 DOUBLE—WALLED PIPE [ ) 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(ES1 (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> r [ ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> Ill ( l 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT RECUIPED TO COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CAS# (IF M:NOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 7 03 <br /> ( i 01 f ) 02 i i 03 <br /> ( ) 01 ( f 02 ( ) 03 <br /> E ) <br /> 01 [ ) 02 ( 1 03 <br /> ( r al ( r 02 c ) 03 <br /> ( ) 01 c ) 02 ( r 03 <br /> 1 01 f ) 02 ( 1 03 <br /> t <br /> ( ) 01 ( 1 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> LIS CDNTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) al YES (XJ 02 NO <br /> I'HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> FERSCN FILING (SIGNATU*E1 =PHONE W/ARE.A CODE <br /> ::OR LOCAL AGENCY USE ONL <br /> :MINIS{ TING <br /> 'A[GE1—N�^ ' kCITY CODE <br /> COUNTY CODE <br /> / ioN �AL L h7rY <br /> i7ACT PERSON l< /v v4 S PHONE W/APEA CODE <br /> 2! <br /> OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION BATE LOCAL PERMIT ID # <br /> r 3 � ( ) 61 YES ( ) 02 NO <br /> 70185 (10/18/85) <br /> PAGE 2 <br /> f <br />