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v <br />CONTAINER CONSTRUCTION <br />9 STATE IO NUMBER 00000011196003 <br />E. 1 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING [ 1 04 PHENOLIC LINING 1 1 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. 1 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT f 1 09 OTHER: <br />I VI PIPING <br />1. ABOVEGROUND PIPING: f 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />1. UNDERGROUND PIPING) f I 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH l ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) 1 ) 04 PRESSURE (XI 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII kEAK DETECTION <br />( ) 01 VISUAL (X) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br />f ) 06 GROUND WATER MONITORING WELLS l 107 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />TF YOU CHECKED YES TO IV -F YOU ARE NOT REQUIRED TO CCMPLETC TMIS SECTION <br />CURRENTLY <br />STCPED <br />PREVIOUSLY <br />STC -ED <br />DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( 1 03 <br />( ) 01 <br />( 1 02 <br />( ) 03 <br />( l O1 <br />( ) 02 <br />( ) 03 <br />( 1 Ol <br />1 ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( 101 <br />( ) 02 <br />( ) 03 <br />( 1 Ol <br />l ) 02 <br />l ) 03 <br />( ) Ol <br />( ) 02 <br />( 1 03 <br />( 1 Ol <br />1 ) 02 <br />( ) 03 <br />( ) Ol <br />( 1 02 <br />( ) 03 <br />■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 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 />'EPSON FILING (SIGNATURE) PHONE W/AREA CC OE <br />D <br />FOR LOCAL AGENCY USE ONLY <br />FAT!NG AGENC I' ) ) N. f 1 CITY CODE (COUNTY CCDE <br />CONTACT PERSON -W/AREA CODE <br />CATE OF LAST INSPECTION IN COMPLIANCE <br />PERMIT APPROVAL GATE TRANSACTION 047E 1: ID C <br />f ! <br />01 YES ( ) 02 NO <br />1• HSC04-070185 (10/18/85) PAGE 2 <br />