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CONTAINER CONSTRUCTION STATE I0 NUMBER 00000013259001 <br /> E. ( ) O1 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING �) 04 HENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED tX) 08 UNKNOWN f ) 09 OTHER: <br /> F. ( ) O1 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> t ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING:E <br /> Ol DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE ) 04 PRESSURE f ) 05 SUCTION (X1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: 01 DOUBLE-WALLED IPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE ) 04 PRESSURE ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ,(X) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 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 /> .F YOU CHECKED YES TO IV-F YOU ARE NOT P.EQUIRED TO COMPLETE THIS SECTION <br /> CUPRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> STORED STOPED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> f ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) <br /> on ( ) 02 ( 1 03 <br /> L__)_0_1 ( <br /> ( ) O1 ( ) 02 - ( ) 03 I I I <br /> I ._ 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 O1 ( 1 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> [ ) 01 ( 7 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 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 /> THIS FORM HAS BEEN CO LETED UNDER T PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON PILI ISI R ) <br /> PHONE W/AREA ODE <br /> �� Z <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE <br /> 1 COUNTY CODE <br /> aaa✓✓✓CVJJ !7 CITY <br /> 3 <br /> CONTACT PERSON <br /> PHO E <br /> w/(L�111yRE� <br /> ( tP�V� <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10118/85) <br /> PAGE 2 <br />