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STATE I❑ NUMBER 00000037606001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING l l 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP l ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN l ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CDNCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> t CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ] 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS l 7 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 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 ARE NOT RERUIRED TO COMPLETE THIS SECTION <br /> CURPENTLY PPEVIDUSLY DELETE CASA (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STCPEO <br /> ( ) OS f ) 02 ( ) 03 <br /> l ) <br /> 01 f 1 02 ( ) 03 <br /> l ) 01 f ) 02 ( ) 03 <br /> ( 7 01 ( l 02 ( ) 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) O1 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t ) <br /> 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 f ) 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 F M HAS BEEN CO PLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PER N F LING (SSG AT PHONE W/AREA CODE <br /> 6 v4 . <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN ATi�-ADE NCY� CITY CODE COUNTY CODE <br /> CON T PERS PN NE W/AREA CODC �J /G <br /> �z��� <br /> DATE 7 LAA3%�N/PECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO A <br /> O/�V// ( l Ol YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />