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STATE 10 NUMBER 004,40030902001 <br />CONTAINER CONSTRUCTION <br />E.'( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING t l 05 GLASS LINING <br />( ) 07 UNLINED (X) OS UNKNOWN ( ) 09 OTHER= <br />F. ( ) 01 POLYETHLENE WRAP 0 ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br />(X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES)t ) 04 PRESSURE ( ) 05 SUCTION ( d 06 UNKNOWN ( l 07 NONE <br />B. UNDERGROUND PIPING( ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 95 SUCTION t ) 06 UNKNOWN ( 3 07 NONE <br />VII LEAK DETECTION <br />,l 01 VISUAL FN 02 STOCK INVENTORY ( 104 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND PATER MONITORING WELLS t ) 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 REgUIREO TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />F ) 01 <br />t ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />t l 01 <br />( ) 02 <br />( ) 03 <br />t ) OI <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ), 03 <br />01 <br />( ) 02 <br />( ) 03 <br />t ) 01° <br />( ) 02 <br />( ) 03 <br />( ) OL <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 10I 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 FTNG (SI AT i° PHONE W/AREA CODE <br />A <br />t LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY <br />4j <br />— <br />CITY O <br />COUNTY CODE <br />CONTACT PERSON <br />u <br />PHONE W/AReEEA CODE <br />2 <br />DATE OF LAST INSPECTION' <br />IN COMPLIANCEPERMIT <br />APPROVAL DATE <br />TRANSACTION <br />DATE <br />LOCAL PERMIT ID # <br />( ) 01 <br />YES ( ) 02 .NO <br />HSC04-070185 (10018/85) PAGE 2 <br />