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STATE I0 NUMBER 00000012644001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 O1 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER <br /> F ( )(01 06LTARHORNE WRAPASPHALT IO)02 VINYLWRAPPING ( ] 03 CATHODIC PROTECTION (X] 04 UNKNOWN f 1 05 NONE <br /> VI PIPING <br /> A. ABOVEGROUNO PIPING ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ] 04 PRESSURE f ) 05 SUCTION fXl 06 UNKNOWN 07 NONE <br /> ( l <br /> B. UNDERGROUND PIPING ( 1 O1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ( ) VISUAL <br /> GROUND( ) 02 STOCK WATER MONITORINGNWELLS ((11007VAPOR <br /> PRESSURESNIFF <br /> TESTWELLS(X)( 05 09 NONESENSOR 10INSTRUMENT <br /> r <br /> vI IF YOU CHECKED Yes COMPOSITION <br /> POSITIO V'F YOU a OFOT MATERIALS <br /> AT ED ID S STORED E THIS SEN IDUNDERGROUND CONTAINERS <br /> rOURPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT VSE COMMERCIAL NAME) <br /> STORED <br /> ( ) 02 [ 1 03 <br /> f 1 02 ( 1 03 <br /> l ) 02 ( ) 03 <br /> ( 1 O1 t ) 02 ( ) 03 <br /> ( ) 01 ( 102 ( ] 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ] 01 ( l 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 O1 YES (XI 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 /> PHONE W/AREA CODE <br /> PERSON FILING (SIGNATURE) <br /> FOR LOCAL AGENCY USE ONLY COUNTY CODE <br /> CITY CODE <br /> ADMINISTRATING AGENCY <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> �LCCAL # <br /> ( ) 01 YES ( ) 02 NO <br /> PAGE 2 <br /> MSC04-070185 (10/18/851 <br />