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STATE ID NUMBER 000DO048924DO3 <br /> CONTAINER CONSTRUCTION <br /> E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( } 03 EPDXY LINING ( l 04 PHENOLIC LINING [ 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION, (X) 04 UNKNOWN t ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING' ( ) 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) i ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ] 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) E ) 04 PRESSURE i 1 05 SUCTION ( } 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY t 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 uoU`1D WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ] 09 NONE [ } 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED YES TO iV-F YCU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPPENTLY PREVIO;:SLY DELETE CASG (IF KNCWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOEED STOPED <br /> c 1 01 ( r 02 ( ) 03 <br /> ( ] 01 ( ) 02 f ) 03 <br /> i } 01 ( ) 02 ( ] 03 <br /> f ] 01 ( 1 02 ( l 103 <br /> f ] 01 f ) 02 ( 1 03 <br /> ( 3 01 ( ) 02 t } 03 <br /> ( ] 01 ( 1 02 ( 1 03 <br /> ( 3 01 t } 02 ( 1 03 <br /> ( r 01 ( ] 02 f ) 03 <br /> ( J 01 ( 1 02 ( 1 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 SEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE A140 CORRECT. <br /> FEP.SON FILING fSIGNATUP.E ) PHONE W%AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ACMINISTPATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT FERSCN PHONE W/,APEA CODE <br /> DF.TE OF CAST INSPECTION IN COMPLIANCE PEP.MIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( l 01 YES ( J 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> y <br />