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STATE IB NUMBER 00000014147002 <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( 1 02 ALKYD LINING i l 03 EPDXY LINING ( ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> ( ) 07 UNLINED (XI 08 UNKNOWN ( ) 09 OTHER: <br /> F. [ 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING 1 ] 03 CATHODIC PROTECTION (X) 04 UNKNOWN [ ) 05 NONE <br /> ( ) 06 TAP. OR ASPHALT ( i 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING= ( ) 01 DOUBLE—WALLED PIPE t ) 02 CONCRETE—LINED TRENCH { ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING! ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( 3 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) d ) 04 PRESSURE 05 SUCTION C 1 06 UNKNOWN t ) 0' <br /> ONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY [ 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> l <br /> )10V6 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST (X) 09 NONE ( i 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED YES TO IV-F YOU ARE NOT REgUIREO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STCPED STOPED - <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> { 1 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( 1 03 <br /> [ i 01 ( ) 02 1 ) 03 <br /> f ) 01 t ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( ) O1 [ ) 02 ( ) 03 <br /> 01 ( 1 02 t ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> LIS CONTAINER LOCATED ONAN 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 /> ON LIN (S N PH NE W/ARE CODE �, <br /> LZ)L -+�-G� r <br /> FPR LOCAL AGENCY USE ONL <br /> CITY CIE COUNTY CODE <br /> ADISTPATNG AGENCY <br /> #� <br /> CONTAC PERSON n PHO E W/AR A CODE <br /> vl FYI_ f/ <br /> DATE OF LAST INSPECTION IN COMP PNCE PERMIT APPROVAL DATE TRANS.ACTICN DATE LOCAL PERMIT ID ? <br /> Q ) Q1 YES C ) 02 NO <br /> PAGE 2 <br /> HSC04-070135 (10/18/85) <br />