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' STATE IO NUMBER 00000003452003 <br /> CONTAINER CONSTRUCTION <br /> E. ( 4 01 RUBBER LINED ( l 02 ALKYD LINING ( } 03 EPDXY LINING f 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLE14E WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (Xl 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 102 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: t l 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH C r 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION { ) 06 UNKNOWN ( } 07 NONE <br /> VII LEAK DETECTION <br /> ( ) O1 VISUAL (Xl OZ STOCK INVENTOR�( ) 04 VAPOR SNI�WELL�S( 05 SENSOR INSTRUMENT <br /> ( 06 GROUND WATER MONITORING WEL07 PRESSURE NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED YES TO IV-F YOU ARE NOT PEQUIRED TO COMPLETE THIS SECTION <br /> CUDPENTLY PPEVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME.) <br /> STOPED STORED <br /> ( T 01 ( l 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> E ) 01 ( ) 02 f 1 03 <br /> ( i 01 C 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( l 03 <br /> ( l 01 ( ) 02 ( 1 03 <br /> ( l <br /> 01 ( 1 02 ( 1 03 <br /> [ 1 01 ( ) 02 ( 1 03 <br /> [ 1 01 ( r 02 ( ) 03 <br /> i 1 01 ( ) 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR P055IBLE SYNONYMS <br /> FISCONTAINER LOCATED ON AN AGRICULTURAL FARM? E ) O1 YE5 [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 ) P ONE W/ARE.A CODE ,/ <br /> FOR LOCAL AGENCY USE ONLY <br /> ACMINISTP.AT NG A'-N'Y , L CIT1��DE GDUNTY CODE <br /> CC ( Pr} �O A i I l(--+ JC <br /> CONTACT PE;SON PyONE W/.AREA CODEQ <br /> A - b C\l is <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT .APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />