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CONTAINER CONSTRUCTION <br /> STATE IO NUMBER 00000065722001 <br /> E. ( 1 01 RUBBER LINED f 1 02 ALKYD LINING <br /> f ) 07 UNLINED (X1 08 lR8(NOWN f 1 09 OTHER: EPDXY LINING ( ) 04 <br /> F. I 1 01 POLYETHLENE WRAP F'F(ENOLIC LINING f 1 05 GLASS LINING <br /> ( ) 06 TAR f 1 02 VINYL WRAPPING <br /> OR ASPHALT ( ) 09 OTHER: ( ) 03 CATHODIC PROTECTION <br /> (X) 04 UNKNOWN [ ) 05 NONE <br /> VI PIPING <br /> A• ABOVEGROU))p PIPING: <br /> (CHECK APPROPRIATE BOXES) ( 1 01 DOUBLE-WALLED PIPE <br /> ( 1 04 PRESSURE f 1 05 S( ) 02 CONCRETE-LINED TRENCH <br /> B• UNOERGROUNp PIPING: UCTION (X) 06 f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 01 DOUBLE-WALLED PIPE ( ) 02 C � ( ) 07 NONE <br /> ( ) 04 PRESSURE ( ) 05 SUCTION RETE-LINED TRENCH <br /> ( ) 06 UNKNOWN ( ) 07fHONG3 GRAVITY <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL f ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> ( ) Ob GROUND WATER MONI70RING HELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TERIO COMPLALS ETE RED E THIS SEN UNDERGROUND CONTAINERS <br /> ION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f 1 01 ( 1 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol [ ) 02 ( ) 03 <br /> 1 1 01 f ) 02 f 1 03 <br />( ) 01 f ) 02 ( ) 03 <br />( ) 01 f 1 02 ( ) 03 <br /> 1 ) <br /> al f ) 02 ( ) 03 <br />( CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> S FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> lSON FILING (SIGNATURE) <br /> PHONE W/AREA COOL, <br /> R LOCAL AGENCY USE ONLY <br /> INISTRATING AGENCY <br /> CITY CODE <br /> COUNTY CODE <br /> TACT PERSON <br /> PHONE W/AREA CODE <br /> E OF LAST INSPECTION IN COMPLIANCE <br /> ( ) 01 YES ( ) 02 NO PERMIT APPROVAL OgTL, TRANSACTION GATE <br /> LOCAL PERMIT IO a <br /> r070185 (05/05/86) <br /> PAGE 2 <br />