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STATE IO NUMBER 00000048386001 <br /> CONTAINER CONSTRUCTION <br /> E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN f ) 09 OTHER: <br /> F. f 1 01 POLYETHLENE WRAP ( 7 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 1 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ] 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ) 04 PRESSURE HE105 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ,�( 1 <br /> 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS f 7 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST (X) 09 NONE f ) 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 /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> 1 ) Ol ( ) 02 f ) 03 <br /> ( 1 <br /> 01 ( ) 02 f ) 03 <br /> f ) <br /> 01 ( ) 02 f ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ] <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 /> PERSON F O IONATUR PHO E DE W/AREA CO <br /> .04 <br /> z - 6S/ZY <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN iTRATIN AG'-NCY CITY CODE COVNTY CODE <br /> CONTACL,PERSON �� P E W/A EA CODE <br /> ✓1 <br /> DATE OF IAST INSPECTION IN COMPLIANCE PERMIT APPROVAL GATE TRANSACTION DATE LOCAL PERMIT I0 # <br /> ( ) O1 YFS f 1 02 NO <br /> HSC04-070185 (10/18/85) ` J PAGE 2 <br /> r <br />