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• % STATE I0 NUMBER 00000062064003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. l ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ] 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 0.1 DOUBLE-WALLED PIPE ( ) 0.2 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 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 ( ) 05 SUCTION ( ) 016 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY f l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) b7 PRE SURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKEO YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS .SECTION <br /> CUP.PEN'TLY PREVIOUSLY DELETE CA$# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 f ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( T 02 ( ) 03 <br /> ( ) 01 ( )_ 02 ( L 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( 1 02 f 1 03 <br /> f ) <br /> al ( ) 02 ( 1 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> CHECK STATE. BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN. COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON F I G URE) a'wo"I W/APEA CODE <br /> FOR L CAL AGENCY SE ONLY <br /> AOMI NI TRATil: h'CV n/ m/ CITY CODE COVNT Y�CODE <br /> a<! !lilt R /F' <br /> CONTACT 7;5 " �� /'e PH�jS A7�' DE���G <br /> DATE OF/ASTN$PECT(iION IN COMPLIANCE .PERMIT APPROVAL DATE TRANSACTION GATE LOCAL PERMIT ID # <br /> JZ �G1F� I <br /> 08 YES ( ) 02 NO <br /> HSC04-070185 110/18/85) PAGE 2 <br />