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ilk STATE 1T) NUMBER 00000054350002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ] O1 RUBBER LINED ( ) 02 ALKYD LINING 1 ) 03 EPDXY LINING l 1 04 PHENOLIC LINING 1 ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP l 1 02 VINYL WRAPPING 1 ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN l 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 1 ) 05 SUCTION 1 1 06 UNKNOWN 1 ) 07 NONE <br /> B. UNDERGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 01 VISUAL (X) 02 STOCK INVENTORY t l 04 VAPOR SNIFF WELLS l 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS 1 1 07 PRESSURE TEST f 1 09 NONE l ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF "OU CHECKED 1ES TO IV•F 1OU APE NOT P!CJIPEJ TO COMPLETE THIS SECTION <br /> CUPP!NTL)' PP!VIOUSLY DELETE CAS# IIF KNOWN) CHEMICAL 100 NOT USE COMM!PCIAL NAME , <br /> STOP!' STOPED <br /> 1 1 <br /> 01 l 1 02 ( 1 03 I I I <br /> ( ) 01 ( 1 02 f l 03 <br /> ( ) 01 f ) 02 ( 1 03 <br /> f 101 ( 1 02 f ) 03 <br /> l l <br /> 01 ( 1 02 ( ) 03 <br /> 1 ) <br /> 01 f ) 02 ( ) 03 <br /> ( ) <br /> 01 l 1 02 ( ) 03 <br /> f 1 <br /> 01 l ) 02 ( ) 03 II I <br /> ( 1 01 f 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> R CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES (XI 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 /> RlPSON FILIN^u 1520PHONE W/AREA C0 <br /> AY0 � <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY C00[ <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 1 I OI YES 1 1 02 NO <br /> iSC04-070185 (10/18/85) PAGE 2 <br />