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STATE I <br /> CONTAINER CONSTRUCTION <br /> FE , 1 OE <br /> LINEA t ) 02 ALKYD LINING { ) 03 EPDXY LINING ( } 04 PHENOLIC LINING [ ) 05 GLASS LINING <br /> f INED (X) 08 UNKNOWN1 09 OTHER) 0HLENE WRAP { ) 02 VINYL WRAPPING03 CATHODIC PROTECTION (X) 04 UNKNOWN i ) 05 NONE <br /> S OR ASPHALT ( ) 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) ( 104 PRESSURE ( } 05 SUCTION ( ) 06 UNKNOWN f 1 07 NONE <br /> B. UNDERGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK UNDERGROUND <br /> PIPINGRIATE BOX(ES) <br /> (X) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN i 1 07 NONE <br /> VII LEAK DETECTION <br /> FjVISUAL t } 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS l ) 05 SENSOR INSTRUMENT <br /> Ob GROUND WATER MONITORING WELLS t 1 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER= <br /> VIII CHEMICAL COMPOSITJION OF APE NOT REQUIRED TO CS STORED <br /> s(:N NDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> STOPED STCREO <br /> t ) 01 S ) 02 t ) 03 <br /> ( } 01 ( ) 02 [ 1 03 <br /> ( 1 01 ( ) 02 E ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> [ ) 01 ( 1 02 ( 1 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> t ) 01 [ D 02 ( ) 03 <br /> ( ) 01 i ) 02 ( ) 03 <br /> i ] 01 t ) 02 ( ) 03 <br /> ( 1 01 ( } 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR P05SIBLE SYNONYMS <br /> EISCONTAINER LDCATED ON �ANAGRJ�CULTURALFARM? ( ) 01 YES (X1 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 /> PHONE W/AREA CODE <br /> P E S O N F Z L JG (5 �. <br /> FOR OCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> ADMINISTRATING AGENCY <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> PATE OF LAST INSPECTION IN COMPLIANCE <br /> PERMIT APPROVAL DATE TRANSACTION DATE LCCAL PERMIT ID # <br /> t ) 01 YES ( ) 02 NO <br /> PAGE 2 <br /> ISC04-070185 (10/18/85) <br /> i i <br />