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STATE IO NUMBER 00000008496001 <br /> CONTAINER CONSTRUCTION <br /> E. 1 ) 01 RUBBER LINED f ) 02 ALKYD LINING 1 ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f l 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. 1 ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 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 (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04-44 PRESSURE f 1 05 SUCTION ( ) 06 UNKNOWN 1 7 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY ( 7 04 VAPOR SNIFF WELLS f ) 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-P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS% (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STCRED STORED <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) <br /> al ( 7 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 f ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ] 03 <br /> ( ) <br /> 01 f ) 02 ( ] 03 <br /> R 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 HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON ING (SIO URE) PHONE W/AREA CODE cy <br /> FO LOCAL AGENCY USE ONLY <br /> ADMI NISiRAJjHO AGENCY CITY CODE COUNTY CODE <br /> G <br /> CONTA T PEPSON PHONE /AREA CODE <br /> Q <br /> IrPDATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL OATS TRANSACTION DATE LOCAL PERMIT ID R <br /> ( ) 01 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />