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STATE IO NUMBER 00000008382007 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( J 03 EPDXY LINING C J 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED f ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( l 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAF. OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: i l 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION IX) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( l 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( l 04 PRESSURE (X) 05 SUCTION f l 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> t ) 01 VISUAL f ) 02 STOCK INVENTORY f l 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 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 /> CUERENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAMED <br /> STOPED STORED <br /> (X) O1 ( ) 02 ( ) 03 161714111 <br /> r ) 01 I ) 02 ( ) 03 <br /> ( ) 01 ( J 02 ( l 03 <br /> ( ) 01 f 1 02 ( l 03 <br /> ( ) of t ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( ) 01 ( D 02 ( ) 03 <br /> t ) 01 t ) 02 ( 1 03 <br /> ( l 01 t ) 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL COBE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? I ) 01 YES IX) 02 NO <br /> THIS FORM HAS BEEN COMPLETED ER THE PENALTY OF PERJURY ANO, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON E ' ,�(Si UP. - PHONE 7W/A E CODE <br /> FOR LOCAL AGENCY USE ONLY ��ttJJ <br /> ADMINISTP4TIN3 AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON 6 PHO E W/AREA CODE <br /> t It tAnm <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES C ) 02 NO <br /> HSC04-070165 (10/18/85) PAGE 2 <br />