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• STATE I0 NUMBER 00000002918011 <br /> CONTAINER CONSTRUCTION <br /> E. ( l 01 RUBBER LINED f ) 02 ALKYD LINING f 103 EPDXY LINING t ) 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (XI 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 7 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f 7 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE fX) 05 SUCTION f 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> lX) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> t ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STARED <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f l <br /> 01 ( ) 02 ( ) 03 <br /> ( 7 01 ( ] 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 7 01 ( 7 02 ( ) 03 <br /> ( ) <br /> 01 ( l 02 ( ) 03 <br /> ( l 01 f l 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 f ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( l 03 <br /> +� CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON ANAGRICULTURAL FARM? ( ) 01 Y02 NO <br /> THIS FO HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> EP.,S F LING (S NAT E PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY �S� CITY CODE COUNTY CODE <br /> JrAq� iJ God G <br /> CONTACT PERSON PHONE W/AREA CODE <br /> L �2 U / 2�4 _ gy8 -7�/// <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> i <br /> HSC04-070185 (10/18/85) PAGE 2 <br />