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.yi STATE ID NUMBER 00000050198001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED l 1 02 ALKYD LINING l 1 03 EPDXY LINING l 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( 1 07 UNLINED (X) OB UNKNOWN ( 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION 1X1 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT 1 109 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) OS GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI l ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 101 DOUBLE-WALLEO PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI l 1 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN 1 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL ( ) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 1 ) 06 GROUND WATER MONITORING WELLS 1 1 07 PRESSURE TEST (X1 09 NONE 1 ) 30 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU C"ECKEO YES TO IV-F YOU -PE NOT Pf OUIRED TO COMPLETE THIS SECTION <br /> CUA-ENTLY PPEVICUSLY DELETE CAST 121 KNOWN CHEMICAL (00 NOT USE COMMERCIAL NAME( <br /> STOPEO STOPED <br /> (X) Ol ( ) 02 1 1 03 WASTE WATER (PROCESS OR INDUSTRIAL) <br /> ( ) 01 ( 102 ( 1031111111111111 <br /> 1 ) 01 ( 1 02 1 1 03 <br /> ( I 01 ( ) 02 ( I 03 <br /> l ) 01 ( 1 02 1 1 03 <br /> ( I 01 1 1 02 l 1 03 <br /> ( 1 01 1 1 02 ( ) 03 <br /> 1101 ( 102 11031111111111111 <br /> 1 1 Ol ( 1 02 ( 1 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> ( ) 01 O 02 1 1 031_L_I_LLLLI <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> �IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 1X1 02 NO <br /> THIS FOPM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> i <br /> 'P r:SCN F:IIND ISC:':="J:EI PHONE W/AREA CCOE <br /> FOR LOCAL AGENCY USE ONLY <br /> v:S r <br /> -ZEN - _-- -IIITCI TI COOP COVVT� CNe <br /> -'4Ts,T =�PiON PHONE Y.'AaEA CODE <br /> �D CTE <ST IVSPEG:Cu v CCY .<u PfoMIT <PPROIAI CATf Ta<NS<CTTCu OA- �lCCsl C Y T ID e <br /> 01 'ES Ci v0 <br /> (,5CC4-070185 (10/18/85) PAGE 2 <br /> _ _ i <br />