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� i r <br /> STATE ID NUMBER 00000002264 <br /> CONTAINER CONSTRUCTION <br /> ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( 1 04 PHENOLIC LINING [ 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION 1 ) 04 UNKNOWN (XI 05 NONE <br /> f 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> PIPING <br /> OVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> rEHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE f 1 05 SUCTION (XI 06 UNKNOWN ( ) 07 NONE <br /> DEP.GROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> NECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( 105 SUCTION ( 106 UNKNOWN f ) 07 NONE <br /> : T LEAK DETECTION <br /> X 01 VISUAL f 7 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> r-) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST 1 ) 09 NONE 1 1 10 OTHER: <br /> CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> PPRNTLY PPEV:OUSLY DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> T. EO STORED <br /> I-01 ( ) 02 ( 1 03 <br /> 01 ( ) 02 f 1 03 <br /> 1-01 ( ) 02 1 1 03 <br /> 01 ( ) 02 ( ) 03 w <br /> _)1 ( ) 02 f ) 03 <br /> 01 ( 1 02 ( ) 03 <br /> )1 ( ) 02 ( ) 03 <br /> 1 01 ( 1 02 1 ) 03 <br /> R ( ) 02 f 1 03 <br /> I O1 ( 1 02 f 1 03 <br /> C :CK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> C^NTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X1 02 NO <br /> r <br /> i FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, 70 THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> 5 FILING f N�$HgEI � PHONE W/ARCA CODE <br /> R LOCAL AGENCY USE ONLY <br /> 1I_STRATING AGENCY CITY CODE COUNTY CODE <br /> LT T PERSON PHONE W/ARG CODE <br /> } <br /> 5 <br /> LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 4 <br /> ( ) 01 YES 1 ) 02 NO <br /> S (10/18/85) PAGE 2 <br />