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• 0 <br /> CONTAINER CONSTRUCTION <br /> STATE Iia NUMBER 40000038917402 <br /> £ { } 01 RUBBER LINED ( ) 02 ALKYD LINING [ } <br /> (X) 07 UNLINED ( ) 08 UNKNOWN 03 EPDXY LINING <br /> ( ) 09 OTHER: <br /> ] 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> F. { ) 01 POLY£THL£tJ£ WRAP ( ) 02 VINYL WRAPPING <br /> (Xl fl6 TAR OR ASPHALT ( ) 09 OTHER: ! ] 03 CATHODIC PROTECTION { ) 04 UNKNOWN <br /> V I PIPING ( ) 05 NDFrE <br /> A. ABOVEGROUND PIPING: ~�l <br /> (CHECK APPROPRIATE BOX(ES) ( d 01pDOUBLE—WALLE4 PRESSURE D PIPE 5 SUCTION <br /> ! ] 02 CONCRETE—LINED TRENCH ! ) 03 GRAVITY <br /> B. UNDERGROU?JD PIPING: ! ) 06 UNKNOWN ( ) 07 NONE <br /> (CHECK APPROPRIATE BOXES) ( } 01 DOUBLE—WALLED PIPE i J 02 CONCRETE—LINED TRENCH { <br /> fXJ 04 PRESSURE ( ) 05 SUCTION ( J 06 UNKNOWN f ) 07 NONE <br /> J 03 GRAVITY ~—� -- <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ] 04 VAPCR SNIFF WELLS ( ) 05 SENSOR IN <br /> ( TRUMENT <br /> S <br /> ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST [ J 09 NONE <br /> VIII CHEMICAL COMPOSITION OF MATl— ) 10 OTHER: <br /> ORED <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE sIr <br /> THIS NUNDERGROUND <br /> CJ`PENTLY PREVICUSLY DELETE CONTAINERS <br /> STORED STOPED CAS# (SF KNOWN) <br /> oz oz ( n3 <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> ( ) ( ] J <br /> f ) 01 ! ) 02 ( ) 03 <br /> ( ) of ( ) 02 ( ) 03 <br /> ( ) O1 If ) 02 ( ) 03 <br /> ( l <br /> 01 ( } 02 ( } 03 <br /> { ) 01 ( J 02 ! ) 03 f <br /> If ) 01 d ) 02 ( } 03 ! <br /> f ) <br /> 01 ( ) 02LLD <br /> d ) 03 <br /> f J 01 ( } 02 ( ) 03 <br /> ( ) 01 f ) 0£ ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES [X) 02 NO <br /> 1IS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF <br /> PERJURY AND, TO THE BEST OF MYON <br />/EPSFF (SIGNATURE! -----~ —— KNOWLEDGE, <br /> PHONE WlAREA CODE IS TRUE AND CORRECT, <br />�0�! ✓ .� <br />\ <br /> OR LOCAL AGENCY USE ONLY 2- <br /> JMINISTRATING AGENCY <br /> CITY CODE <br /> INTACT pEPN [� COUNTY CODE <br /> PN E dl/A EA CODE <br /> TE OF LAST INSPECTION <br /> IN CO+`iPL:ANCE <br /> ( ) Or YES D2 NO PERMIT APPROVAL GATE TRANSACTION DATE <br /> — ( ) <br /> LOCAL PERMIT IO # <br />)4-070285 (IO/Z8/85) <br /> PAGE 2 <br />