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. '�" • • STATE IO NUMBER '00000050198001 <br /> r <br /> CONTAINER CONSTRUCTION <br /> E. 1 ) 01 RUBBER LINED 1 1 02 ALKYD LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 105 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN 1 ) 09 OTHER: <br /> F. ( I 01 POLYETHLENE WRAP 1 l 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN 1 105 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> I PIPING <br /> A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> S. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE 1 102 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE f 1 05 SUCTION ( 1 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL ( 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS 1 ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> III CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU C-9-KED YES TO IV•F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PPEVICUSLY DELETE CAST IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STOPED <br /> (X) O1 ( ) 02 ( ) 03 WASTE WATER (PROCESS OR INDUSTRIAL) <br /> f l <br /> 01 ( 1 02 ( ) 03 <br /> ( ) 01 l ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 1 ) 01 ( 1 02 ( 1 03 <br /> 1 ) 01 ( 1 02 O 03 <br /> l ) 01 ( ) 02 ( ) 03 I I <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( I 01 YES (X) 02 NO <br /> HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSCN FILIN3 (S:GNATURE) PHONE W/APEA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> A:":N:STPAT:NO AGENCY CITY CODE COUNTY CODE <br /> CONTACT PEPSDN PHONE W/APEA CODE <br /> CITE CF LAST :NS:ECT:DN IN CCMRL:ANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PE-MIT :0 E <br /> O1 ''_S . ) 02 NO <br /> SC04-070185 (10/18/85) PAGE 2 <br />