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0 0 STATE ID NUMBER 00000042134006 <br /> CONTAINER CONSTRUCTION <br /> E. t 1 01 RUBBER LINED ( ) 02 ALKYD LINING (X) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> i ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP [ l 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN [ ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( I 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: [ ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPP.OPRIATE BOXCES) ( ) 04 PRESSURE (X) 05 SUCTION ( l 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELL'S ( 1 07 PRESSURE TEST ( l 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 PECUIPEO TO COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> (X) 01 ( 1 02 ( ) 03 6 7 6 4 1 1 1 .1. 1 1 j * ACETONE (DIMETHYL KETONE, 2-PROPANONE) <br /> c ) 01 c ) 02 ( 1 03 <br /> i ) 01 [ 1 02 ( ) 03 <br /> ( 1 01 [ ) 02 ( 1 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 f ) 03 <br /> t ) 01 ( 1 02 ( l 03 p <br /> i 1 01 ( 1 02 t l 03 <br /> ( ) 01 ( ) 02 ( 1 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 /> PERSON FILING (SIGNATURE) PHONE W,'aFEA CDDE <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMINISTPATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PEPSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLI4NCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> C ) 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />