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STATE ID NUMBER 00000012290002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> f ) 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( 7 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 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(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( 7 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST f ) 09 NONE (X) 10 OTHER: LINE LEAK DETECTOR <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO !V-F YOU ARE NOT REQUIPEO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( 1 01 ( ) 02 [ 1 03 <br /> ( 1 01 ( 1 02 f ) 03 <br /> f ) 01 ( 7 02 f ) 03 <br /> ( 1 <br /> 01 f ) 02 ( ) 03 <br /> f ) 01 [ ) 02 ( ) 03 <br /> ( 1 O1 ( 1 02 ( ) 03 <br /> f 1 01 ( 1 02 ( ) 03 <br /> f ) 01 f l 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( l 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 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 IGNATVRE PHONE W/AREA CODE <br /> -7-12ZC6; <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING XC���/ CITY CODE COUNTY CODE <br /> CONTACT PERSON '•V/ CAi PHONE W/AREA CODE <br /> 66 <br /> TATE OF LAST INSP CTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION. DATE LOCAL PERMIT ID # <br /> ���� -�/ ( ) O1 YES ( 1 02 NO <br /> :04-070185 (10/18/85) PAGE 2 <br />