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• • STATE I0 NUMBER 00000006826001 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 7 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A ABOVEGROUND <br /> BOX(ES) ( ( 0104 PRESSUREL€� 1)PE 02 05 SUCTION CONCRETE-LINED( ) 06UNKNOWN�( )H 3 GRAVITY <br /> 07(NONE <br /> B. UNDERGROUND PIPING: ( ) 01 OOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL 02 Y ( 4 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUN R MONITORING WELLS f ') 07 PRESSUR TEST ( ) 09 NONE ( ) 10 OTH£Rt <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 /> CUFPENTLY PRE`:IOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( 1 02 ( 1 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( 7 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) OS ( ) 02 ( ) 03 <br /> ( 7 <br /> 01 ( 7 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> (t CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 YES (XI02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> FILING (SIGN TU ) <br /> PHONEcCW/`REA <br /> PE � <br /> �e l�� 6 6 6 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADM NISTRA AGENCY I,n L CITY�0O � �� ` COVNTY CODE �y <br /> rj y <br /> CPEP ON ^, PHONE W/AREA CODE <br /> DATE OF TLAS INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCA) PERMIT ID # <br /> 01 YES ( 1 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />