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STATE ID NUMBER 00000038894002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING t ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> (X) 07 UNLINED ,( ) 08 UNKNOWN ( 109 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP fi J 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (. ) 04 UNKNOWN t ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER.: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING= ( ) 01 DOUBLE—WALLED PIPE t ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE, `( ) 05 St)CTION ( ) 06 UNKNOWN d ) 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION E 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL (X) 0'2 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( J 07 PRESSURE TEST ( ) 09 NONE t ) 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 /> CUP.RENTLY PREVIOUSLY DELETE CAS(# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( D O1 f ) 02 ( ) 03 <br /> t ) 01 E b02 ( ) 03 <br /> ( ) 01 t J 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> Q1 ( ) 02 ( ) 03 <br /> d ) 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 /> PER80N F LI ( IGNATURE3 PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTAC ERSO <br /> PtIONE AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 Y# <br /> f ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />