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• • STATE IO NUMBER 00000054350001 <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING 1 1 05 GLASS LINING <br /> 1 ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> i F. f ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> f ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l 105 SUCTION ( 1 06 UNKNOWN ( 107 NONE <br /> S. UNDERGROUND PIPING: ( I 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> F( ) O1 VISUAL (XI 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS [ ) 07 PRESSURE TEST l 1 09 NONE 1 ] 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECFEO )ES TO IV-F YOU APE NOT PEQUIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASO IIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STOPED STOPED <br /> f 101 1 , 02 O03LUIIIIIIII <br /> 1 ) 01 f l 02 ( ) 03 I I <br /> f ) 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 f ) 02 ( 1 03 <br /> iI 1 01 ( 102 1 ) 03 <br /> I ( ) 01 1 102 t 1 03 <br /> IC f ) 01 f ) 02 1 1 03 <br /> f ) 01 l ) 02 ( ) 03 <br /> f ) 01 f ) 02 ( ) 03 <br /> 1 ) 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 /> FE-SO4 FILING lSI NATVR ) ^ PHONE W/AREA CODE <br /> co <br /> o - 9 3116 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATINO AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/APEA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION OATC R <br /> 1 1 <br /> 01 YES 1 ) 02 NO LOCAL PEMIT :D P <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br /> • J <br />