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. . STATE IO NUMBER 00000016769001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. 1 ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 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 f ) 07 NONE <br /> VII LEAK DETECTION <br /> f 1 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS 1 ) 07 PRESSURE TEST l 1 09 NONE ( ) 10 OTHER: <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 PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( <br /> STCPED STOPED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f 1 01 ( 1 02 ( 1 03 <br /> ` ( ) 01 f ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> l l Ol ( ) 02 1 ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( 1 02 ( 1 03 <br /> !. ( l Ol ( ) 02 ( ) 03 <br /> ( ) Ol 1 ) 02 ( l 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> K CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> SIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f l 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 /> EPSON F L NO r$IGNAT PHONE W/APER CODE <br /> ojo�P /K�4�vA6ER o20`�- s -.2 <88 <br /> FOR LOCAL AGENCY USE ONLY <br /> DMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> �C ONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT :D R <br /> ' ( ) 01 YES ( 1 Oi NO <br /> SC04-070185 (10/16/85) PAGE 2 <br />