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STATE 10 NUMBER 00000018304008 <br /> CONTAINER CONSTRUCTION <br /> E. { ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING [ 1 05 GLASS LINING <br /> (X) 07 UNLINED I 1 08 UNKNOWN ( ) 09 OTHER. <br /> F. [ l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> (X) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING• f 1 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH E ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( l 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES1 ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 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 RE&UIREO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STC?ED STORED <br /> I 1 01 ( ) 02 f ) 03 <br /> ( ) O1 ( 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 1 1 03 <br /> S ) 01 ( ) 02 I 1 03 <br /> ( ) 02 ( ) 02 ( 1 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 t ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> { ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FCP.M HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILIN (SIG TURF ) PHON W/AREA CCDE <br /> 334-33S <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTFATING AGENCY CIT DE COUNTY CODE <br /> CONTACT P PSON PHONE W/APE.k CODE <br /> DATE OF LAST INSPECTIONIN COMPLIANCE PERMIT APPROVAL 'DATE TRANSACTION DATE LOCAL PERMIT 10 <br /> # <br /> h( ) 01 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />