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STATE 10 NUMBER 00000063817002 <br /> CONTAINER CONSTRUCTION <br /> E. [ ) 01 RUBBER LINED [X) 02 ALKYD LINING f ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING l 1 05 GLASS LINING <br /> ( ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. l 1 01 POLYETHLEHE WRAP ( ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ] 05 NONE <br /> (X) 06 TAR OR ASPHALT ( 7 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 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: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN f ) 07 NONE <br /> VTI LEAK DETECTION <br /> g(Xl 01 VISUAL (X1 02 STOCK INVENTORY f 1 04 VAPOR SNIFF HELLS ( ) OS SENSOR INSTRUMENT <br /> (X) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST f 1 09 NONE ( 1 30 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 CASE (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) 01 ( l 02 ( ) 03 i6 FUEL OIL <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 t ) 02 ( 103 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 O1 f ) 02 ( 1 03 f <br /> ( l <br /> 01 ( ) 02 ( ) 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 /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATUREI • PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSONPHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 <br /> 01 VES f 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> +� <br />