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CONTAINER CONSTRUCTION STATE IO NumBER 00000035002014 <br /> E. 1 1 O1 RUBBER LINED 1 1 02 ALKYD LINING I 1 03 EPDXY LINING 1 1 04 PHENOLIC LINING 1 1 OS GLASS LINING <br /> f 1 07 UNLINED (%) 08 UNKNOWN ( 1 09 OTHER: <br /> F. 1 1 01 POLYETN EEl NN WRAP 1 ) 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION 1X1 04 UNKNOWN ( 1 OS NONE <br /> 1 1 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) of DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) OS GRAVITY <br /> (CHECK APPROPRIATE BO%1 ES1 ( 1 04 PRESSURE ( ) OS SUCTION ( ) 06 IDfKNO(M I ) 07 NONE <br /> B. UNDERGROUNDPPR PIPING: ( ) O1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 4EO 04 PRESSURE J2) Os SL)CTION ( ) 06 UNKNOWN 1 107 NONE —I <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL f INVENT Y 1 1 04 VAPOR SNIFF WELLS ( ) OS SENSOR INSTRUMENT <br /> 1 1 06 GROUND NATER MONITOR (ELLS (xS 07 PRESSURE TEST <br /> IX) 09 NONE l 1 30 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> -F YOU CMECY.ED tES TO :V-I YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CU:ClNTLY :cE\':CUSLY DELETE CAS# IIF KNOWN) <br /> CTD"``0 STC=EC CHEMICAL IOD NOT USE CCr.CEPCI*I NAr.! 1 <br /> ( 1 <br /> 01 -- 1 ) 02 ( ) 03 -- ------- <br /> 1 1 <br /> 01 1 1 02 ( 1 03 I I I <br /> 1 1 01 ( ) 02 1 ) 03 <br /> 1101 () 02 1 03 LJ I I I I <br /> ( ) (1l f ) 02 f 1 03 1 <br /> 1 1 01 I ) 02 f 1 03 I I I <br /> ( 1 Ol ( 1 02 f I OS — <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( 1 01 l ) 02 1 ) 03 <br /> ( I Ol 1 1 021 1 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (%) 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 /> %F:SOr//I12N0 1jIDNAT ----- <br /> / / ) PMO C AREA t00[ <br /> FOR LOCAL AGENCY USE ONLY / <br /> AOM;NISTPATINO AGENCY - <br /> / , /�� / ,/n ` fjA/(�/� CITY CODC <br /> •fi «�///1�?•fAC^�Y�Flt�f/ `/./ ✓�� COUNTY CGDE <br /> 1 I <br /> COMTACCF /LPSON� / PMOM! W/A ILA COD[ <br /> It ,Qin r? /• 7 ?ci <br /> OAT[ 01 (AST INSI[C TION IN COMPLIANCE PERMIT APPPOVAI CAT L TRANSACTION DAT! LOCA RE OMIT IO # <br /> ick G ) oI Yes 1 ) OR No <br /> i <br /> Ixoao7oles f loneies 1 /y/�Q /� .S <br /> PAGE 2 <br />