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STATE IO NUHBER 00000054749007 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYO LINING ( ) 03 EPDXY LINING l 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> l ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. 1 1 01 POLYETHLENE WRAP 1 ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN 1 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION 1 ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS l ) 05 SENSOR INSTRUMENT <br /> 1 ) 06 GROUND WATER MONITORING WELLS ( ) 07'PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> :F YOU CHECKED YES TO IV-F YOU ARE NOT REOUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVICVSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> f ) Ol ( ) 02 ( ) 03 j <br /> f ) 01 l 1 02 ( ) 03 <br /> f 1 Ol ( ) 02 ( ) 03 <br /> 1 1 Ol ( ) 02 ( ) 03 <br /> ( 101 ( ) 02 f 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f ) 01 ( 1 02 ( ) 03 <br /> l ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 7 02 ( 1 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSI LE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPL UNDER NALTY OF RJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (S:GNATUR PHONE W/AREA CODE <br /> D <br /> FOR LOCAL AGENCY USE NLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPIIANCC PER <br /> APPROVAL DATE TRANSACTION DAT! LOCAL PERMIT ID R <br /> f l O1 YES 1 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />