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STATE 19 NUMBER 00000012781001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED t 1 02 ALKYD LINING ( ) 03 EPDXY LINING f l 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( l' 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. (X) 01 POLYETHLENE WRAP ( J 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION € ) 04 UNKNOWN [ ) 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 BOXtES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: F ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN [ ) 07 NONE <br /> VII LEAK DETECTION <br /> �( ) <br /> 1 VISUAL ( ] 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( J 05 SENSOR INSTRUMENT <br /> 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECYEC YES TO IV-F YOU ARE NOT REPUIPED TO COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> i s 01 t 1 02 ( 1 03 <br /> ( ) 01 ( J 02 t 1 03 <br /> E 1 <br /> 01 ( J 02 t o 03 <br /> [ 1 O1 [ 1 02 ( ) 03 <br /> ( a 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( 1 01 ( a 02 ( l 03 <br /> i 1 01 ( a 02 ( ) 03 <br /> [ l 01 E l 02 ( 1 03 <br /> ( 3 01 ( l 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> EISCONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 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 FIL3 .3NATURE ) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY ( � CIT C DE <br /> COUNTY CODE <br /> Q� L <br /> CONTACT [EPSON <br /> PHONE W/,4R'.4 CODE <br /> P�(fiL L Q <br /> DATE CF LAST INSPECTION IN COMPL NCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( 1 LOCAL PERMIT ID # <br /> ( ) 01 YES <br /> 02 NO <br /> iSC04-070185 (10/18/85) <br /> PAGE 2 <br />