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STATE IO NUMBER 00000061629001 <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED 1 ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. 1 1 01 POLYETHLENE WRAP 1 ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION 1X1 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION l 1 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL ( ) 02 STOCK INVENTORY (X) 04 VAPOR SNIFF WELLS f 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 YCU CH!CKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PPCVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAM[) <br /> STORED STORED <br /> f ) 01 1 1 02 1 ) 03 <br /> ( ) 01 f ) 02 ( 1 03 <br /> f l <br /> 01 t 7 02 1 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( l 03 <br /> ( 1 01 ( ) 02 f ) 03 <br /> 1 ) <br /> 01 l ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 1 11 f 1 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 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 /> PERSON FILING (SIONATURE) PHONE W/ARCA COD! <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AO[NCY CITY CODE COUNTY COD[ <br /> CONTACT PERSON PHONE W/AREA COD[ <br /> DATE OF LAST INSPCCTION IN COMPLIANCE PERMIT APPROVAL OAT[ TRANfACTION'DAT[ LOCAL PERMIT ID R <br /> ( ) 01 Y12 ( ) Ot NO <br /> HSC04-070165 (10/16/85) PAGE 2 <br /> • • <br />