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STATE IO NUMBER 0000002003€001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING i l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 055 NONE <br /> [ ) 06 TAR OR ASPHALT [ ) 09 OTHER" <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH t ) 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 f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DET'ECTICN <br /> ['4H01VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> t l 06 GROUND WA7ER MONITORING WELLS ( ) 07 PRE55URE TEST ( ) 09 NONE f ) 10 O <br /> THER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOJ CHECKED YES TO IV-F YOU APE NOT REWIRED TO COMPLETE THIS SECTICN <br /> CURRENTLY f"P.EVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STCP?.D <br /> ( 3 01 ( ) 02 ( l 03 <br /> ( ) 01 ( ) 02 t ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( )"o1 t 1 02 ( ) 03 <br /> t ) 01 ( 1 02 1 ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> w <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 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 /> PEPWN FILING (SIGNAT P. PHONE W/AREA CODE ` el <br /> FOR LOCAL AGENCY USE ONLY <br /> A.DMINIS EATING AGENCY CITY CODE COUNTY CODE <br /> NCZY al, -3- <br /> CONT T PERSON P NE W/AREA CODE <br /> DAT= OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID <br /> ) 01 YES ( 7 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />