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STATE IO NUMBER 00000011683002 - <br /> CONTAINER CONSTRUCTION <br /> E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) OB UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( l 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER= <br /> VI PIPING ' <br /> A. ABOVEGROUND PIPING: ( ) Ol DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> S. UNDERGROUND PIPING f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (IX 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN l 1 07 14ONE <br /> VII LEAK DETECTION <br /> ( ] 01 VISUAL Od l102 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS j 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ()<f 07 PRESSURE TEST (J!T 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 /> CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) 01 ( ) 02 ( ) 03 <br /> f I Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> (� <br /> 01 ( ) 02 ( ) 03 <br /> 1 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 101 l ) 02 ( ) 03 <br /> 1 1 Ol f ) 02 ( ) 03 <br /> ( I <br /> 01 ( l 02 ( 1 03 <br /> f 1 <br /> 01 ( 1 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 /> FEP N ZLIN7 IS UR PHON W/AR CODE <br /> 3ZHSono <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTR ATINO OCNCV � CITY ZCODE COUNTY CODE <br /> fjo <br /> CONTA PERSON PH,PNE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID R <br /> ( ) <br /> 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> llb-i ..Of <br />