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STATE 10 NUMBER 00000019572002 <br /> CONTAINER CONSTRUCTION <br /> E. t 1 01 RUBBER LINED f l 02 ALKYD LINING t ) 03 EPDXY LINING ( l 04 PHENOLIC LINING t a 05 GLASS LINING <br /> (X) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: <br /> F. t 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) C5 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN i ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION f i 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f 1 05 SENSOJ� INSTRUMEN <br /> 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: I <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CA" (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 C ) 02 f a 03 <br /> O 01 ( ] 02 4 1 03 I I I I I I I I I l l <br /> ( ) 01 ( a 02 ( ) 03 <br /> ( ) 01 f ) 02 t 1 03 <br /> i t l 01 t ) 02 f ) 03 <br /> 1 Ll <br /> I t ) 01 ( ) 02 f 1 03 <br /> II € 1 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 f ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ) 01 f ) 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 /> 'HIS FORM HA EN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> ".r ON IL ( NAT PHONE W/.AREA CODE <br /> LOCAL AGENCY E ONLY <br /> STRATING AGENCY CITY CODE COUNTY CODE <br /> ,EPSON PHONt W/AREA CODE <br /> T INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) OI YES f ) 42 NO <br /> 10/18/85) PAGE 2 <br />