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9 0 <br /> STATE 10 NUMBER 00000019572001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED f ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED S ) 08 UNKNOWN ( ) 09 OTHER. <br /> F. [ ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> { 1 06 TAR OR ASPHALT ( ) 09 OTHER* <br /> VI PIPING <br /> A. 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 /> B. UNDERGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE f ) 05 SUCTION [ i 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> i ) 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE (() 10 OTHER: ,o <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU .ARE NOT REPUIPEO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASt tIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOTED <br /> ( J 01 ( ) 02 ( ) 03 <br /> i 1 01 ( ) 02 ( 1 03 <br /> [ ) 01 ( J 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 { ) 02 ( 1 03 <br /> ( ) <br /> 01 { 1 02 ( ] 03 <br /> ( J 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 t 1 03 <br /> ( ) O1 ( ) 02 ( ) 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 EN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> pcp N FIGNATU PHONE fJ/AREA CODE <br /> FOR LOCAL AGENCY US ONLY <br /> ADMINISTRATING ,%.�CY J CITY CODE COUNTY CODE <br /> L:l <br /> CONTACT PERSC N PHONE W/AREA CCDE <br /> �(S <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATELOCAL PERMIT ID # <br /> ( ) Ol YES ( ) 02 NO <br /> HSC04-070185 (10/18/851 PAGE 2 <br />