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STATE ID NUMBER 00000012408001 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( } 03 EPDXY LINING ( 1 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> (X) 07 UNLINED f 1 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR CR ASPHALT ( 1 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( l 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( } 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> �t .G1 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS ( l 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 YOU :;'E NOT PEOUIPEC TO COMPLETE THIS SECTION <br /> CUFF;NTLY ?DEVIOUSLY DELETE CAS# (IF KNCWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STCPED STOFED <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) G2 ( 1 03 <br /> ( ) <br /> 01 i 1 02 ( 1 03 <br /> [ ) <br /> 01 { ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> 01 ( } 02 1 1 03 <br /> ( l <br /> 01 ( 1 02 f 1 03 <br /> ( ) 01 ( } 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 f l 03 <br /> CHECK STATE BOARD CHEMICAL CCDE 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 /> FE;SCN FILING (SIGNA URE) _ PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMINISTPATZNG AGENCY CITY CODE COUNTY CODE <br /> CONTACT PEFSCN Pti E W/A EA CODE <br /> ,GATE OF LAST INSPECTION IN COMPLIANCE FERMIT APPPCVAL DATE TRANSACTION DATE LOCAs, PERMIT ID # <br /> t ) 11 YES t 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />