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STATE 10 NUMBER 00000062186004 <br /> CONTAINER CONSTRUCTION <br /> E. ( 101 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> (X) 07 UNLINED ( 1 08 UNKNOWN I ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 104 UNKNOWN (X1 05 NONE <br /> ( 7 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( U 07 NONE <br /> B. UNDERGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN (X) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS f ) O5 SfNSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (w 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV•F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ] <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> 1 Ol ( ) 02 ( 1 03 <br /> f ) <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 1.1 1 1 1 1 1 1 _j <br /> 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 f ) 02 ( 1 03 <br /> ( l 01 ( ) 02 ( l 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 YES (X) 02 NO <br /> THIS F M HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> P-P N ILING (SG RE) ` 'PH NE W/AREA CO❑ <br /> 1/m <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY <br /> CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( ) ( 1 LOCAL PERMIT ID # <br /> 01 YES 02 NO <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br />