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w 0 <br /> STATE IO NUMBER 000000127t31CO2 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED [ ) 02 ALKYD LINING ( J 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f ) 07 UNLINED (X) 06 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP C 1 02 VINYL WRAPPING ( } 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ) 05 NONE <br /> ( l 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( J 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( l 06 UNKNOWN ( } 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION f } 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( a 02 STOCK INVENTORY 4 l 04 VAPOR SNIFF WELLS [ l 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST f ) 09 NONE ( l 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKEO 7ES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUP.PENTLY PP.EVIOUSLY DELETE CAS:: (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 i ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 0). ( ) 02 ( ) 03 <br /> ( } 01 ( ) 02 r a 03 <br /> i ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( J 02 ( } 03 ISI I i <br /> ( J 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( J 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 COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON PI G (SIGNATUPEI PHONE W/AP,EA CODE <br /> C�-da <br /> FOR LOCAL AGENCY USE ONL <br /> Av IN:STRATIN^a AGENCY / CITOq� COUNT)" CODE <br /> CONTACT PERSON T PHON W/A�A`CpgE 4 3 'Q <br /> DATE OF LAST INSPECTION IN CC PLIANCE PERMIT APPROVAL DATE TRANS.gCTION DATE LOCAL PERMIT ID x <br /> ( ) 01 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br />