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STATE IO NUMBER 00000014943020 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN f ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 STICTION ( ) 06 UNKNOWN f ) 07 NONE <br /> B. UNDERGROUND PIPING: [ ) Ol DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> {CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION l ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> A ) 01 VISUAL 11%g 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS (h1 07 PRESSURE TEST tW 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> l 1 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 - ( 1 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> f 1 01 ( ) 02 ( 1 03 <br /> f 1 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> al [ 1 02 ( 1 03 <br /> l 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 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 (S GNATURE) PHONE W/AREA CODE <br /> O 2- <br /> FOR LOCAL A ENCY USE ONLY <br /> Al llMILV <br /> ISTRATINO AOEyCY CITY CODE COVNTY CODE <br /> J 3 <br /> CONTACT PERSO PHONE W/ARCA CODE <br /> rr - <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DAT! LOCAL PERMIT ID # <br /> ( 1 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) �` ' � PAGE 2 <br />