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• 0 <br /> STATE FO NUMBER 00000009692003 <br /> CONTAINER CONSTRUCTION <br /> E. ( } 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( } 04 PHENOLIC LINING ( } 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER. <br /> F. C } 01 POLYETHLENE WRAP ( } 02 VINYL WRAPPING ( } 03 CATHODIC PROTECTION f } 04 UNKNOWN i } 05 NONE <br /> (X) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ] 01 DOUBLE-WALLED PIPE ( f 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH r-k 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE 44400" SUCTION ( } 06 UNKNOWN ( ) 07 D_NE <br /> VII LEAK DETECTION <br /> [�7)106IGROUND(WATOR <br /> 0VSUAL } 2 STOCK INVENTORY f l 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE f ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT R,ECUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( } 01 f } 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( )_.03 <br /> ( } 01 ( } 02 ( ) 03 <br /> ( } Ol ( l 02 ( 1 03 <br /> [ ) 01 ( ) 02 ( 1 03 <br /> ( } 01 ( ) 02 1 ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNDWLEDGE� IS TRUE AND CORRECT. <br /> PEF.SCN FILING t N E7 PHONE W/AREA CODE <br /> 2a 33// <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATING AGENCY _ CITY CODE COUNTY CODE <br /> LAG c PSL t S r <br /> CONTACT PERSON PHONE W/AREA CODE <br /> TOM 15"ek, <br /> DATE OF LAST IN E ION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> Z2-- <br /> 2 r ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br /> L`_ <br />