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9 STATE IO NUMBER 00000011285002 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING l 1 05 GLASS LINING <br /> l 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING f 103 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f ) 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 90 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> (W 01 VISUAL fX) 02 STOCK INVENTORY f l 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> T ) 06 GROUND WATER MONITORING WELLS (.4-07 PRESSURE TEST t ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF FCU CHECKED YES TO IV-F YOU ARE NOT RECUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> t ) Ol ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 f 7 02 ( ) 03 <br /> ( l 01 f 1 02 ( 1 03 <br /> f ) 01 ( l 02 ( ) 03 <br /> ( ) Ol ( l 02 ( 1 03 <br /> f ) 01 ( 1 02 ( 7 03 <br /> ( ) <br /> 01 ( ) 02 l ) 03 <br /> 01 ( 1 02 ( l 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f 1 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 /> P'-RS FILING (SIGNATUR ) PHONE W/AREA CODE <br /> ppy����•• <br /> OGL7L <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> UtJI 4 e a <br /> CO NTA T PERSON PHONE W/AREA CODE <br /> r <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> �,��� ( ) 01 YYEEE'a l 1 02 NO <br /> HSC04-070185 (10/18/85) ' PAGE 2 <br />