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1 <br /> STATE ID NUMBER 00000036871001 <br /> CONTAINER C`ONSTRUCTIO <br /> E. ( ) 01 RUBBER LINES} ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( } 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. t } 01 POLYETHLENE WRAP f ) -02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( D 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE f 102 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN 041 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(:ES) W) 04 PRESSURE ( 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> l 01 VISUAL02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> 06 GROUN WA ER MONITORING WELLS 07 PRESSURE TEST t l 09 NONE ( D 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> - IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNCWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t ) 01 ( ) 02 ( ) 03 <br /> E ) 01 ( } 02 ( ) 03 <br /> ( 301 ( } 02 ( ) 03 , <br /> ( ,) 01; t ) 02 ( ) 03 <br /> t D 01 ( ) 02 ( ) 03 <br /> D 01 ( ) 02 ( ) 03 <br /> } 01 ( } 02 ( ) 03 <br /> t l 01 t ) 02 ( ) 03 <br /> E 01 ( ) 02 ( ) 03 <br /> E ) 01 ( ) 02 ( ) 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 (SIGNATUP ® e Ae PHONE W/AREA COD <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODECOUNTY CODE <br /> e5 <br /> CONTAC PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ya? { ) 01 YES t ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />