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STATE IO NUMBER 00000065391009 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP f J 02 VINYL WRAPPING ! 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT 1 l 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) i ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING' ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE (X) 05 SUCTION f J 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS (X) 05 SENSOR INSTRUMENT <br /> ( l 06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST ( J 09 NONE ( 1 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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) 01 ( ) 02 ( ) 03 1510161614191 -FILVER CYANIDE <br /> (X) 01 ( ) 02 ( ) 03 1 5 i 5 0 B POTASSIUM CYANIDE <br /> (X) 01 1 ) 02 ( ) 03 171614171114151 SODIUM CHLORIDE <br /> (X) 01 ( ) 02 ( ) 03 1114131313191 SODIUM CYANIDE <br /> (X) 01 ( ) 02 ( ) 03 11.1311101713121 SODIUM HYDROXIDE <br /> (X) 01 ( ) 02 ( ) 03 151711111-51 CYANIDES, INORGANIC SALTS (tcu (- UV <br /> ( ) 0i i ) 02 ( ) 03 <br /> [ ] 01 ( ) 02 1 ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 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 KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERS ("SIGNATURE) PHONE AREA G DE <br /> -a �' 7SR L&,� �D o - <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (05/05/86) PAGE 2 <br />