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STATE IO NUMBER 00000011182001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING [ 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ! 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 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 i ! 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> A ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST i ! 09 NONE ( ) 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECY.ED YES TO IV-F YOU A.'E NOT RECJIRED TO COMPLETE THIS SECTION <br /> CURFCNTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMEPCIAL NAME) <br /> STORED STOPED <br /> 01 [ ) 02 1 1 03 <br /> ( I 01 f 1 02 ( ) 03 <br /> 1 ) 01 ( 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> 1 ) 01 ( 1 02 ( 1 03 <br /> ( ) 01 ( i 02 ( 1 03 <br /> ( I 01 ( ) 02 ( ) 03 <br /> f 1 01 ( ! 02 ( ! 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 t 1 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS COIITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES IX) 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 /> PERSON FILING 1 SIGN4TUPE 1 P>J:ONE :I.'4FEA CCOE <br /> FOR LOCAL AGENCY USE ONLY <br /> nC!!IN=STAAT=N.G AGEN- ( .• CITY CCOE COUNTiCODE <br /> r-( <br /> CONTACT PERSON PHONE W,APEA CODE .� <br /> 04TE CP LAST iNSPECT:ON IN CC':OLI4NCE PERMIT 4PPROVAL DATE TF-NS4CTICN OATE LOCAL PEPMIT I0 # <br /> ( 1 01 YES A 02 NO <br /> KSC04-070185 (10/18/85) PAGE 2 <br />