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STATE ID NUMBER 00000014862003 <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER <br />F. ( ) 01 POLYETHLENE WRAP ( ) 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: ( l 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( D 05 SUCTION ( ).06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: ( l 01 DOUBLE -WALLED PIPE t ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTI ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( ) 03 p <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />f ) Ol <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />(' ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />{ ) 01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br />PHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PER N PILIS GNATURE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINT,STRATING AGENCY CITY CODE COUNTY CODE <br />-,45bw ja,�,q zm 46m� <br />CONTACT PERSON PHO'E W/AREA CORE <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE JLOCAL PERMIT 10 # <br />( ) 01 YES ( ) 02 NO <br />NSC04-07018S (10/18/85) PAGE 2 <br />