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STATE IO NUMBER 00000030588002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( } 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP t } 02 VINYL WRAPPING t l 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> (X) 06 TAR OR ASPHALT i ) 09 OTHER. <br /> VI PIPING <br /> A. ABOVEGP,OUNO PIPING: ( ) 01 DOUBLE-WALLED PIPE i r 02 CONCRETE-LINED TRENCH C ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE (Y) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: [ ) 01 DOUBLE-WALLE PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ) 05 SUCTION ( r 06 UNKNOWN t ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( ) 02 STOCK INVENTORY t l 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ] 07 PRESSURE TEST ( ) 09 NONE t l 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF "YOU CHECKED YES TO IV-F YOU APE NOT 9E9UIPEO TO COMPLETE THIS SECTION <br /> CURRENTLY FFEVICL'SLY DELETE OAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STCFED STOPED <br /> ( r 01 ( ) 02 ( ) 03 <br /> f ! 01 [ 1 02 ( 1 03 <br /> ( l 01 ( r 02 t } 03 <br /> ( } <br /> 01 i } 02 [ J 03 <br /> ( 1 01 t 1 02 ( J 03 <br /> C 1 01 ( } 02 ( ) 03 I <br /> t 1 01 ( l 02 t ) 03 <br /> ( 1 01 f ) 02 [ 1 03 <br /> ( 1 01 C ) 02 C ) 03 <br /> ( l 01 ( ) 02 ( 1 03 <br /> * 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 /> kP,PSON FILING (SIGNATURE ) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT ON PHONE W.'APEA CODE <br /> DATE OF LAST INSPECTION IN toPLIANCEPE RMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID iY <br /> YES ( ) 02 NO <br /> C04-070185 (10/18/85) PAGE 2 <br />