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STATE IO NUMBER 00000051438001 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> fX) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f 1 01 POLYETHLENE WRAP [ ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION f l 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 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) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN l ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( ) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( 105 SENSOR INSTRUMENT <br /> 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE f 110 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 f ) 03 <br /> ( 7 01 ( ) 02 ( ) 03 1 <br /> f ) Ol ( ) 02 - ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 101 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ! ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( 1 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 (SIGNATURE) - PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT TO # <br /> f ) O3 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />