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STATE I0 NUMBER 00000012411003 <br /> CONTAINER CONSTRUCTION <br /> E. 1 ) 01 RUBBER LINED ( ) .02 ALKYD LINING ( 1 03 EPDXY LINING f ] 04 PHENOLIC LINING ( ] 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 06 UNKNOWN ( ) 09 OTHER: <br /> 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A ABOVEGROUND <br /> PRIATE.BOX(ES) ( ( 0104 PRESSURELED ) PE 02 05 SUCTION CONCRETE-LINED( ) 06UNKNWN ( 7H07( 3 GRAVITY <br /> NONE <br /> B. UNDERGROUND PIPING ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( l 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> wi 01 VISUAL (X1 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS t ) 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( ) 01 1 ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> t I <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( .) 03 <br /> ( 1 Ol ( 1 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> t ) <br /> 01 ( ] 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> i 1 01 ( ) 02 t ) 03 <br /> it CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM°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 /> E SON FILING (SIGNATURE) PHONE W/AREA CODE <br /> Z' ZoS � <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />