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STATE ID NUMBER 00000001492001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ] 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING f ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 1 05 NONE <br /> (X) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l 1 05 SUCTION ( 1 06 UNKNOWN l ) 07 NONE <br /> B. UNDERGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( l 04 PRESSURE (X) 05 SUCTION l ) 06 UNKNOWN 1 ) 07 NONE ' <br /> VII LEAK DETECTION <br /> PW 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS l 1 05 SENSOR INSTRUMENT <br /> 'l�) 06 GROUND WATER MONITORING WELLS 00 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKEO YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 Ol f ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) Ol t ) 02 ( 1 03 <br /> ( ) Ol f 1 02 ( 1 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br /> t ) Ol ( ) 02 1 l 03 <br /> ( ) 01 f ) 02 ( 1 03 <br /> f 1 Ol ( ) 02 ( 1 03 <br /> ( ) 01 f 1 02 ( l 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINE�LOCATED ONAN AGRICULTURAL FARM? t ) O1 YES �(X) 02 <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) , PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGING I � O - CITY CODE COUNTY COD[ <br /> lda LLin, 1} f(c <br /> CONTACT PE SONPHONE W/AREA CODE <br /> n <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID L <br /> ( 1 all YES 1 1 02 NO <br /> �� <br /> RSC04-070185 110/18/851 4+ PAGE 2 <br /> OLI- <br />