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0 STATE I0 NUMBER <br />CONTAINER CONSTRUCTION <br />000013082002 <br />E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f 1 05 GLASS LINENS <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br />(X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING) ( ) 01 DOUBLE -WALLED PIPE ( l 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE. <br />VII <br />LEAK DETECTION <br />DELETE CASA (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( 1 03 <br />( I <br />01 VISUAL (X) 02 STOCK INVENTORY l <br />1 04 VAPOR SNIFF WELLS <br />f l 05 SENSOR <br />INSTRUMENT <br />01 <br />( ) 02 <br />( <br />) 06 GROUND WATER MONITORING WELLS ( <br />) 07 PRESSURE TEST ( <br />) 09 NONE (X) <br />10 OTHER: CHECKED FOR WATER <br />BY <br />I VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINER <br />rn rnMF,PTF THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CASA (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( 1 03 <br />(, ] 01 <br />( ) 02 <br />( 1 03 <br />01 <br />( ) 02 <br />( l 03 <br />( ) Ol <br />( l 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />( l Ol <br />( ) 02 <br />( ) 0.3 <br />(,) Ol <br />( 1 02 <br />( ) 03 <br />( 001 <br />( ) 02 <br />( ) 03 <br />( 7 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ] 02 <br />( ) 03 <br />■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYM5 <br />CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br />THE PEMAITY OF OFD_IIIRY AND. TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />115 tUMn MA* occn ..- _. _ <br />'EPSON FILING (SIGNATURE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADM NIST RA ING ADEN CY�ZC�iCITY CODE COUNTY ODE <br />.Hn oa ,st//�a/int ,j%/,f�YiCf `s <br />CONTA T PERSON �. PHONE W/AREA CODE <br />/1�/a�a (?o �fJ X35-32/0 <br />DATE OF LAST IN�S/P(CTION IN COMPLIANC! �r PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO A <br />�Q �S '5 1 ()() 01 YES ( ) 02 NO <br />HSC04-070185 (10/18/85) i <br />PAGE 2 <br />