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C©NTAINFR CONSTRUCTIONSTATE TO NUNbER 00000044782006 <br /> E. ( } OF RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING [ l OS GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION C ) 04 UNKNOWN (X) 05 NONE <br /> f ) 06 TAR OR ASPHALT ( ) 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPINGEE <br /> DOU8LE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (GkiECK APPROPRIATE4 PRESSURE f ) O5 SUCTION (X1 06 UNKNOWN ( ) p7 NONE <br /> B. UNDERGROUND PIPINGDOUSLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( J 03 GRAVITY <br /> (CHECK APPROPRIATE4 PRESSURE (XJ OS SUCTION C 1 OG UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> [��UMD <br /> AL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> WATER MONITORING WELLS ( ) p7 PRESSURE TEST ( } 09 NONE C l IO OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECK-to YES TO IV-F YOU .ARE NOT PECUIRED TO COMPLETE THIS SECTION <br /> C:JZZENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> STORED STOPED CHEMICAL (DO NOT USE COMMERCIAL NA"4E) <br /> (X) 01 ( ) 02 ( ) 03 <br /> #6 FUEL OIL <br /> 01 ( ) 02 ( ) 03 - — <br /> f } 01 ( 1 02 ( 1 03 <br /> ( } 01 ( ) 02 ( } 03 <br /> i ) 01 [ ) 02 I l 03 <br /> ( } 01 f ) 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 C } 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( } 03 <br /> ( 1 <br /> 01 ( ) 02 ( } 03 ! <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 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 /> 7FLOCAL <br /> LING (SIGNAT ) <br /> PHONEW/AREA CCDE24-1 <br /> AGENCY USE ONLY <br /> ADMINISTRA ING AGENCY <br /> 6aly-\ CITY DE COUNTY CODE <br /> CONT CT PERSON <br /> PHONE W/AR DE <br /> 33 76 .5 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( ) <br /> 01 YES f ) 02 NO LOCAL PERMIT ID # <br /> iSC04-070185 (10/18/85) <br /> PAGE 2 <br />