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STATE IO NUMBER 00000065391007 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 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 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION 1 ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH [ 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) { ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( l 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) WT 04 PRESSURE (X) 05 SUCTION t J 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (XJ 01 VISUAL ( 1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS (X) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS i J 07 PRESSURE TEST ( ) 09 NONE ( i 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 CASs! (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (Xl OT { ) 02 ( 1 03 171616141913191 * SULFURIC ACID (-%EbW- <br /> (X) 01 ( 1 02 ( 1 03 171614171011101 * HYDROCHLORIC ACID <br /> (X) 01 ( 1 02 ( ) 03 171414171319141 CUPRIC CHLORIDE <br /> (X) 01 ( ) 02 ( l 03 171710151018101 FERRIC CHLORIDE CIRON CHLORIDE) <br /> (X) 01 O 02 ( 1 03 171711181514191 NICKEL CHLORIDE <br /> 4 1 <br /> 01 ( ) 02 ( ) (13 <br /> ( 1 <br /> 01 [ ) 02 t ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 ( l 03 <br /> ( 1 01 [ 1 02 t 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( J 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 /> PE N INGti S G E PHON W/ARE{ CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> u E, <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> f 3 <br /> 01 YES t 1 02 NO <br /> HSC04-070185 (05/05/86) PAGE 2 <br />