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STATE ID NUMBER. 00000011196002 <br />CONTAINER CONSTRUCTION <br />E. 1 ) 01 RUBBER LINED( 1 02 ALKYD LINING f 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING l ) 05 GLASS LINING <br />1X1 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) O1POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br />( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br />VI PIPING <br />A. ABOVEGRCU'!0 PIPING: l ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH f 1 03 GRAVITY <br />(CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 Ob UNKNOWN 1 107 NONE <br />B. UNDERGROUND PIPING: 1 ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) 1 ) 04 PRESSURE IX) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />I 1 01 VISUAL (X) 02 STOCK INVENTORY ( ) 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 CnECA_D YES TO IV•F YOU APE NOT PEOUIPED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STOPED <br />PPEVICUSLY <br />STORED <br />DELETE CASE IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />f I O1 <br />f ) 02 <br />1 ) 03 <br />( 1 01 <br />1 1 02 <br />( 1 03 <br />1 ) Ol <br />( ) 02 <br />l ) 03 <br />( 1 Ol <br />f 1 02 <br />l 1 03 <br />1 ) 01 <br />( ) 02 <br />( 1 03 <br />f 1 01 <br />f ) 02 <br />( 1 03 <br />f 1 01 <br />( ) 02 <br />1 1 03 <br />1) Ol <br />11 02 <br />1 1 03 <br />( ) 01 <br />f 1 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? ( ) 01 YES 1X1 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 />'EPSON FILING (SIONATUP-I PHONE W/APIA CODE <br />FOR LOCAL AGENCY USE ONLY <br />HSC04-070185 (10/18/85) PAGE 2 <br />