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STATE I0 NUMBER 00000011982001 <br /> CONTAINER CONSTRUCTION <br /> EllolBER LINED ( ) 02 ALKYD LINING ( ] 03 EPDXY LINING f 1 04 PHENOLIC LINING ( ] 05 GLASS LINING <br /> UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> YETHLENE WRAP ( ) 02 VINYL WRAPPING f 103 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ] 06 UNKNOWN ( 1 07 MORE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY (X) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS [ ] 07 PRESSURE TEST ( ) 09 NONE f 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO !V-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) al ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 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 HA EEN COMPLE ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> P N F ING (SIG NAT E) PHON /ARC CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMZ NI ST RATZ NG GENCY CITY CODE COUNTY CODE <br /> G <br /> CONj�.CT PE2S01{- � � ON[ W/AWEA CODE <br /> DATE OF LAST (IINNSSPPPEECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # <br /> ( ) 01 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> r <br />