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STATE IO NUMBER 00000014943023 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( l 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION Ila 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING• l ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 104 PRESSURE (X) 05 SUCTION f l 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f ) <br /> 01 VISUAL Ud 02 STOCK INVENTORY l ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( l 06 GROUNDMER MONITORING WELLS {W 07 PRESSURE TEST fWi-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 /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> al ( ) 02 ( ) 03 <br /> l ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 1 1 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> t ] Ol ( ) 02 ( l 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 KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AOE NCY CITY CODE COUNTY ODE <br /> 3 <br /> CONTA T jPERSONUPHONE W/AREA CGDE <br /> Q <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL OATS TRANSACTION DATE LOCAL PlRMIT ID # <br /> 3 -� 01 YE ) O3 NO <br /> MSC04-070185 (10/18/85) ��( � � PAGE 2 <br />