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STATE IO N UMBER 00000042271002 <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t D 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING t 103 CATHODIC PROTECTION f 104 UNKNOWN ( ) 05 NONE <br />(X) 06 TAR OR ASPHALT t D 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: E } 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK I7E`TECTION <br />01 VISUAL (X) 02 STOCK INVENTORY t l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS (') 07 PRESSURE TEST ( ) 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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />E ) 03 <br />E ) 01 <br />( ) 02 -- <br />( ) 03 , <br />t ) 01 <br />( ) 02 .. <br />t ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( l 03 <br />C ) 01 <br />( ) 02 <br />[ ) 03 <br />{ l 01 <br />( ) 02 <br />t 103 <br />01 <br />( ) 02 <br />f D 03 <br />01 <br />( ) 02 <br />t ) 03 <br />{ ) 01 <br />( ) 02 <br />( l 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 KNOWLEDGEt IS TRUE AND CORRECT. <br />_f FPERSON FIL,95rel I <br />EN (ST URE) PHONE W/AREA CODE <br />" s �f : .. <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />CONTACT PERSp <br />PH 0 W/A EA CODE <br />DATE OF LAST INSPECTION IN COMP-LIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />( ) 01 YES ( ) 02 NO <br />HSC04-070185 (10018/85) <br />PAGE'2 <br />