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0 0 <br /> STATE 10 NUMBER 00000011242001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED { } 08 UNKNOWN ( ) 09 OTHER. <br /> F. { ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION f 1 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) l ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (XI 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> [ ) 06 GROUND WATER MONITORING WELLS t ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER-' <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPRENTLY PREVIOUSLY DELETE CASn (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED srOPED <br /> ( ) 01 ( ) 02 ( 1 03 <br /> I ] <br /> 01 C ] 02 1 l 03 <br /> 11 <br /> 01 f 1 02 ( J 03 <br /> C ) <br /> 01 ( ) 02 C 1 03 <br /> ( ) <br /> 01 t 1 02 ( 1 03 <br /> 1 9 01 ( ) 02 ( ) 03 <br /> 1 ) O1 ( ) 02 ( ) 03 <br /> ( ' 01 l IO2 ( 1Q31 I I I I I I I I I I I I <br /> ( l 01 ( 1 02 ( } 03 <br /> f l 01 1 l 02 ( ' 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IIS CONTAINER LOCATED ON Aft AGRICULTURAL FARM? f ] 01 YES (X) 02 NO <br /> THIS FORM HAS SEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> r`_-SON FIL:N. (S.GNATUFE1 PHONE W.-'AREA CODE <br /> O <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATZNG .GENU( CITY CODE COUNTY CODE <br /> CONTACT PEPSON PHONE W.'AREA CODE <br /> -TE OF LAST INS=ECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT i0 0 <br /> ( I of 'ees ( ) 02 NO <br /> HSC04-070185 ( 10/18/85) PAGE 2 <br />