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CONTAINER CONSTRUCTION STATE I0 NUMBER 00000009554003 <br /> E)'(X) <br /> 01 RUBBEE <br /> NED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING [ 1 04 PHENOLIC LINING ( ) OS GLASS LINING <br /> 07 UND ( 7 O8 UNKNOWN ( ) 09 OTHER: <br /> O1 PO LYETE WRAP ( ] 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f 7 04 UNKNOWN (X) 05 NONE <br /> 06 TARASPHALT ( 7 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ! ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE 60X(ES) ( ) 04 PRESSURE t ) 05 SUCTION ( 7 06 UNKNOWN f 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 7 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> fX) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> (X) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER: INSPECTED BY GOVERNM <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 CAS# (IF KNOWN) <br /> STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( ) 01 ( 7 02 ( ) 03 <br /> f 7 Ol f ) 02 ( 1 03 <br /> ( ) <br /> 01 ( 1 02 f 1 03 <br /> 01 f 7 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> [ ) <br /> 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( 7 02 ( ) 03 <br /> ( ) 01 ( 7 02 ( ) 03 <br /> ( ) O1 ( 1 02 ( ) 03 <br /> ( l 01 ( 7 02 ! ) 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 FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND., TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON Fil SIGNATURE) <br /> PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> FDATE <br /> ISTRATING AGENCY <br /> A/ ;APPROVAL <br /> CITY CODE�VCOUNTY CODE <br /> C/T PERSONv PHONE W/AREA CODE <br /> OF LAST INSPECTION IN COMPLIANCE <br /> Q PERMIDATE TRANSACTION GATE <br /> O ( 1 O1 YES ( ) 02 NO LOCAL PERMIT 20 # <br /> ISC04-070185 (10/18/85) <br /> PAGE 2 <br />