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STATE IO NUMBER 009000 <br /> 21915004 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( 1 07 UNLINED f l 08 UNKNOWN ( ) 09 OTHER <br /> F. f l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( i 05 NONE <br /> ( ) 06 TAR CR ASPHALT f ) 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE [ ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) E ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> l (CHECK APPROPRIATE BOXCES) E 1 04 PRESSURE f ) 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL f ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> l ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER= <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOJ CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPEO STCEEO <br /> i ) 01 ( 1 02 ( ) 03 <br /> f l 01 ( ) 02 ( l 03 <br /> f 1 01 ( 1 02 f l 03, <br /> ( ) 01 ( ) 02 f ) 03 <br /> C ) 01 f ) 02 ( l 03 <br /> f ) <br /> 01 ( ) 02 f l 03 <br /> ( ) 01 ( ) 02 f 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 1 ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL COBE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l O1 YES (X1 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 PILING (SIGNATURE ) PHONE W/APER CODE F7 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATIN3 AGENCY CYTY CODE COUNTY CODE <br /> :CNTACT PERSON PHONE WfARE.4 CODE <br /> DATE OF LAST INSPECTION�C01PLIly:ANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ES ( 7 92 NO <br /> -070185 (10/18/85) PAGE 2 <br />