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CONTAINER CONSTRUCTIONSTATE ID NUMBER 00000042134005 <br /> 0 <br /> E. ( ) 01 RUBBER LINED ( l 02 ALKYD LINING (X) 03 EPDXY LINING C 1 04 PHENOLIC LINING C ) 05 GLASS LINING <br /> ( ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN [ ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING' ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH C ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> (Xl 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( l 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST C ) 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 SECTICN <br /> CUNPENTLY PREVIOUSLY DELETE CAStt IIF KNOWN] CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED SED <br /> (X) 01 f ) 02 ( 1 03 1111111716121 I 1_1 I I I ETHYLENE GLYCOL MONOBUTYL ETHER (BUTYL CELLOSOLVE) <br /> (X) 01 ( l 02 ( } 03 1 3 3 0 2 0 7 1 1 1 1 1 XYLENE, ALL ISOMERS <br /> (Xl 01 ( ) 02 ( ) 03 1110181818131 * TOLUENE (METHYLBENZENE,AROMATIC HYDROCARBON LOW ANALINE) <br /> (X) 01 ( 1 02 ( ) 03 1 2 3 $ 6 4 1 1. 1 1 1 1 BUTYL ACETATE, N-BUTYL ACETATE <br /> (X) 01 ( ) 02 ( 1 03 6 7 6 3 0 1 1 1 1 1 * ISOPROPYL ALCOHOL (2-PROPANOL) <br /> (X) 01 ( ) 02 ( 1 03 9 1 2 0 3 1 1 1 1. 1 1 1 NAPTHALENE <br /> (X) 01 i ) 02 t l 03 PARAFFINS <br /> ( ) 01 ( l 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( l 01 t ) 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 /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSCN FILING SSIGNATURE) PHONE W'AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W%AREA CODE <br /> DATE OF LAST INSPECTION JIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( S 01 YES ( f 02 NO <br /> HSC04-07CI85 (1018/851 PAGE 2 <br />