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00 00 <br /> STATE ID NUMBER 00000059974001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ] 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) Ol DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXtES) f 7 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 SOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> ( > 01 VISUAL [ 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO !V-F YOU APB NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> f 1 <br /> 01 f ] 02 ( l 03 <br /> ( ) O1 f 102 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> l ) <br /> 01 ( 1 02 ( 103 <br /> ( ) 01 f ) 02 [ 1 03 <br /> ( ) <br /> 01 ( l 02 ( ) 03 <br /> ( ) <br /> 01 f ) 02 f ) 03 <br /> ( ) Ol ( 1 02 f 103 <br /> ( 1 Ol f 1 02 1 1 03 <br /> ( 7 OS ( 102 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON ANAGRICULTURAL FARM? ( ) O1 YES(X) 2 NO <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 AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) <br /> 01 YES f 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />