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i <br /> STATE IO NUMBER 00000001870002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING l ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f ) 07 UNLINED (XI 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING l 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN / 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l l 01 DOUBLE-WALLED PIPE I 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION 1 106 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> I I O1 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> ( 1 Ob GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE 1 ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> :F YOU CHECKED YES TO IV-F YOU APC NOT RECUIREO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STCPED <br /> l l <br /> 01 ( 1 02 1 1 03 <br /> 1 1 Ol 1 1 02 ( ) 03 <br /> 1 1 01 ( ) 02 ( ) 03 <br /> 1 ) Ol f ) 02 ( ) 03 <br /> f ) Ol ( ) 02 1 ) 03 <br /> 1 ) Ol ( 1 02 ( ) 03 <br /> ( ) 01 1 ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> l ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> k 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 FILING (SIGNATURE) PHONE W/ARIA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMINISTRATINO AGENCY CITY COD! COVNTY C00! <br /> CONTACT PERSON PHONE W/APEA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DAT! TRANSACTION DATE LOCAL PERMIT ID # <br /> 1 ) Ol YES 1 i OC NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> i i <br />