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STATE I0 NUMBER 00000024753001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING 1 7 04 PHENOLIC LINING f l OS GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER' <br /> F. ( ) 01 POLYETHLENE WRAP 1 7 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN 1 1 05 NONE <br /> 1 ) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t 7 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION t ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS l 105 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS l)0 07 PRESSURE TEST ( ) 09 NONE ( l 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 (DO NOT USE COMMERCIAL NAME) - <br /> STORED STORED <br /> ) 02 ( I03I <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 103 <br /> 1 ) 01 ( ) 02 1 ) 03 <br /> 1 1 01 [ 7 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( l 02 1 1 03 <br /> ( ) 01 [ 102 l ) 03 <br /> x CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> SIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t l O1 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 /> T� <br /> _PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AOM ISTRATING AGENCY ' CITY CODE COUNTY 000E <br /> — 3 <br /> CONTA P SON ^ PHONE W/ARCA CODE <br /> EIJ( Ga9 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DAT[ LOCAL PERMIT ID % <br /> 3_S O1 YES ) 02 NO <br /> ' HSC04-070✓185 (10/18/85) �� PAGE 2 <br />