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CONTAINER CONSTRUCTION STATE 10 NUMBER 00000035874002 <br /> E. ( E01RUBBER LINED C ) 02 ALKYD LINING i 1 03 EPDXY LINING C 1 04 PHENOLIC LINING ( J 05 GLASS LINING <br /> UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER:YETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 1 05 NONE <br /> TAR OR ASPHALT ( ) 09 OTHER <br /> VI PIP TNG <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNQWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) (X) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> f ) <br /> 01 VISUAL {X) 02 STOCK INVENTCRY ( 1 04 VAPOR SNIFF WELLS ( } 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS ( } 07 PRESSURE TEST f ) 09 NONE f 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT RE;UIREO TO COMPLETE THIS SECTION <br /> CJRRENTLY PPIVICUSLY DELETE CAS# (IF KNOWN) <br /> STOPEDSTD.._D PE CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> C ) <br /> 01 ( l 02 f ) 03 <br /> ! 1 01 f 1 02 <br /> f } <br /> 01 ( J 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( D 03 <br /> ( } 01 ( J 02 ( ) 03 - <br /> ( } Ol ( 1 02 ( } 03 <br /> f 1 01 ( l 02 ( ) 03 <br /> ( } 01 ( J 02 ( 1 03 <br /> ! ) <br /> 01 C l 02 ( ) 03 1 -- <br /> ( ) 01 ( ) 02 f ) 03 -� <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> LIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? { ) Ol Y_S (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 /> P RSON F£L' ' (SIGNATUr^rE) <br /> PHONE W/AREA CODE 7i <br /> FOR LOCAL AGENCY USE ONLY <br /> ADM,I NI TPATIN�-AGENCY - <br /> CITY CODE CCJNTY CODE <br /> 0 7clG7�- � <br /> CONTACT PEPSON <br /> PHON W/APF4A CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE <br /> PEPMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> f ) 0; YES f ? 02 NO <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br />' � a <br />