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STATE I0 NUMBER 00000008153001 <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ] 04 PHENOLIC LINING f 7 05 GLASS LINING <br />(X) 07 UNLINED ( ) OB UNKNOWN ( ) 09 OTHER: <br />F. f ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT f 1 09 OTHER: <br />VI PIPING <br />L. 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 />!. UNDERGROUND PIPING• ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT U� <br />( ) 06 GROUND WATER MONITORING WELLS LX 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER:/ o! 0�bkp f. /`S <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />f 1 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) O1 <br />( ) 02 <br />( 1 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />( ) O1 <br />( 1 02 <br />( ) 03 <br />( ) Ol <br />( ) 02 <br />( ) 03 <br />( ) Ill <br />( ) 02 <br />( ) 03 <br />f ) 01 <br />( 7 02 <br />( 1 03 <br />e 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 />ONE AREE � dle - 7 7 3tigDfwd __Pt: <br />FIIE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY <br />CONTACT PERSON <br />CITY CODE <br />PHONE W/AREA CODE <br />COUNTY CODE <br />(DATE OF LAST INSPECTION IIN COMPLIANCE IPERMIT APPROVAL DATE ITRANSACTION DATE (LOCAL PERMIT ID # <br />( ) O1 YES ( ) 02 NO <br />HSC04-070185 (10/18/85) <br />PAGE 2 <br />