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0 0 <br /> STATE IO NUMBER 00000005382006 <br /> CONTAINER CONSTRUCTION <br /> E. { 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR. OR ASPHALT ( 1 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING* ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 9 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( l 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN i 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS i ) 05 SENSOR INSTRUMENT <br /> { ) 06 GROUND WATER MONITORING WELLS t 1 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CU;P ENTLY PPEVICUSLY DELETE CAS# (IF KNOWN) CHE"1ICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STCFED <br /> (X) 01 ( 1 02 ( 1 03 SOLVENTS <br /> (X1 01 ( ) 02 ( ) 03 PAINT THINNER P o o L 0, <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( ) 02 1 1_131H <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> 4 1 01 ( ) 02 ( 1 03 <br /> { 1 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? i ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETE THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> #PERSON I (SIGN �tJR ) PHONE W/AREA CODE <br /> 4L45c( <br /> FOR LOCAL AGENCASE ONLY <br /> ADMINISTRATING AGENCY � ^ �� � CITY CODE COUNTY CODE <br /> Z ( 9 <br /> CONTACT PER SI I� � 06) r l� P}i0�€E WARE)GCDE <br /> L4 T <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 )t <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />