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STATE ZO NUMBER 00000004406002 <br /> CONTAINER CONSTRUCTION <br /> E. f l 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ] 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 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) ( 1 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN l ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ),02 VISUAL (X) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS f l 05 SENSOR INSTRUMENT <br /> 201-06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHEOKEO YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 <br /> 01 ( ) 02 1 ) 03 <br /> 1 ) <br /> 01 ( ) 02 ( ) 03 <br /> 1 ) OS ( ) 02 f ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 1 ) 03 <br /> ( ) 01 ( ) 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, ZS TRUE AND CORRECT. <br /> PERSO. FILING GN.ATUREI PHOj1E W/AREA_ �����/ <br /> FOR LOCAL AGENCY U ONLY <br /> HOMINIS ATZNG ENCY CITY CODE COUNTY CODE <br /> T2rc <br /> CONTA PERSON PHONE W/AREA CODE <br /> L <br /> DATE OF L T INSPECTIONZN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> f ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />