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.� <br /> STATE IO NUMBER 00000035002003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f ) 07 UNLINED (X) OB UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( l 05 NONE <br /> ( ) 06 TAR OR ASPHALT f ) 09 OTHER- <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 7 02 CONCRET€-LINED TRENCH (30 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CDNCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ft04 PRESSURE05 SUCTION f 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL 06 02 ST99LjNYZUIaRY ( ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST (X) 09 NONE ( ) 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 PPEVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 f ) 02 ( ) 03 <br /> ( 1 01 ( l 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 f ) 03 <br /> ( 1 01 ( l 02 ( 1 03 <br /> 1 1 01 ( 1 02 ( l 03 - <br /> l ) <br /> 01 f ) 02 f ) 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 /> PERSONF ING (S NATO ) ^ PHONE /AREA CODE <br /> e � U <. zi <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY '//7/� CITY CODE COUNTY CODE <br /> J- <br /> COyftCT PCR ON PHONE W' <br /> AREA CODE <br /> IW4orf /f%r, �2dV <br /> GATE OF ';TT IySPi CTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ✓✓ b ( ) <br /> 01 YES ( ) 02 NO y� r <br /> HSC04-070185 (10/18/85) ///� J PAGE 2 <br />