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STATE 10 NUMBER 00000011242002 <br /> CONTAINER CONSTRUCTIONE. ( I 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> (X) 07 UNLINED ( J 08 UNKNOWN ( ) 09 OTHER <br /> F. ( 1 01 POLYETHLENE WRAP t 1 02 VINYL WRAPPING ( 9 03 CATHCDIC PROTECTION i ) 04 UNKNOWN (X) 05 NONE <br /> 1 106 TAR OR ASPHALT ( 1 09 OTHER, _ <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 0l DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN 1 1 07 NONE <br /> B. UNDERGROUND PIPING- ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE (X) 05 SUCTION ( 106 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f I O1 VISUAL (X) OZ STOCK INV ENTCRY t 104 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> t ) 06 GRDUJiD WATER MONITORING HELLS ( ) 07 PRESSURE TEST 1 ) 09 NONE [ 1 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECK!D YES TO IV—F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTIDN <br /> CURRENTLY PREVIOUSLY DELETE CASs( (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED I j <br /> O 01 ( ) 02 ( 1 03 1 1L_ l_L <br /> i ) 01 t ) 02 ( ) 03 <br /> ( 1 <br /> 01 l I 02 1 ) 03 <br /> ( 1 01 f ) 02 t ) 03 <br /> ( 1 01 ( J 02 ( I 03 <br /> ( 1 01 ( 102 ( 103 1 1 1 1 1 1 1 1 1 4 4 - <br /> � ) 01 ( ) oz ( ) 03111111111111_l _ -- <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ► 01 ( ) 02 ( ) 031v��LLLLL[� 1 I 1 <br /> t ) 01 t 1 02 t 1 03 I I ( L—LLL_l_LH I I —_-- — — <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> ITS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X1 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 /> 1FERSON FILING (SIGNATURE) PHONE W,APEA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> L_­^:INISTPATINO AGENCY _ --— - CITY CODE CCUNTY CODE <br /> CONTACT PERSON LPHONE W,'APEA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID U <br /> VIES 1 02 <br /> HSC04-070185 (10/18/85) PAGE 2 <br />