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STATE ID NUMBER 00000063247003 <br /> CONTAINER CONSTRUCTION <br /> E. t 101 RUBBER LINED ( ) 02 ALKYD LINING t. D 03 EPDXY LINING { i 04 PHENOLIC LINING { 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. t 101 :POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATEtOOIC PROTECTIOg -f ) 04 uwNom (H) 05 Note <br /> ( D 06'TAR OR ASPHALT ( ) 09=OTHER: <br /> VI, PIPING <br /> A. ABOVEGROUND PIPING: UM 01 DOUBLE-WALLED PIPE ( l"02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( 1 04 PRESSURE ( ) '05 SUCTION t ) 06 UNKNOWN t ) 07 NONE <br /> B. UNDERGROUND PIPING: (tel 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t ) .05 SUCTION 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL y)tl'02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS C ) 07 PRESSURE TEST ( D 09 NONE { ) 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 KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> c ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) ,03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( ) 0'I ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 01 ( ) '02 ( ) 03 <br /> t ) 01 ( ): 02 ( ) 03 <br /> ( ) 01 t ) 02 ( ) 03 <br /> 01 ) 02 ( ) 03 <br /> 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 _FDpqAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERS N F LING (SIGNA RE PH E W EA C D <br /> s <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES ( ) 02 NO <br /> HSC0 -070185 (10/16/85) PAGE 2 <br />