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STATE I0 NUMBER 00000059512001 <br /> CONTAINER CONSTRUCTION <br /> E ( )(0RUBBER LINED <br /> OB UNKNOWN LIN1N09 I ) 03 EPDXY LINING ( 1 04 PHENO <br /> 1 LIC LINING ( ) 05 GLASS LINING <br /> 07 <br /> NED <br /> F. 1 ) O1 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) OS NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING 02 <br /> A. ABOVEGRAPPROPPIPING: <br /> BOX(ES) f ( 0104 UDOUBLE-WALLED PIPE <br /> PRESSURE 05 SUCTION CONCRETE-LINED TRENCH� H 07f NONE <br /> 3 GRAVITY <br /> CHECK <br /> RIATE <br /> B CHECKRAP APPROPRIATEPIPING: <br /> BOX(ES) ( ( 0304DOUBLE-WALLED(X)PIPE <br /> 05 SUCTION CON;R 06EUNKNOWN�EN)H 07( 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 107 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 ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASE (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( 1 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( 1 02 f ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) Ol ( ) 02 f ) 03 <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 FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> A01jINISTRAT.00 AGENCY CITY CODE COUNTY CODE <br /> J ' t <br /> CONTA T PERSON PHONE W/AREA CODE <br /> 1 � <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID S <br /> ( ) O1 YES l 1 02 NO <br /> HSC04-070185 (10/18/85) T4-nK re►no✓e / 9- -8r PAGE 2 <br />