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STATE TO NUMBER 00000035194003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ; ) 04 PHENOLIC LINING l ) 05 GLASS LINING <br /> f ) 07 UNLINED (X) 08 UNKNOWN I ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( } 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ; ) 05 NONE <br /> [ 1 06 TAR OR ASPHALT ( } 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING+ ( 1 O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 104 PRESSURE (X) 05 SUCTION ( l 06 UNKNOWN t l 07 NONE <br /> VII LEAK DETECTION _ <br /> ( ) 01 VISUAL 02 S ; 1 04 VAPOR SNIFF WELLS I ] 05 SENSOR INSTRUMENT <br /> ( ) 06 GROOM MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO CCMPLETE THIS SECTION <br /> CUPRENTLY PP.EVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( } 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> } 01 f ) 02 S ) 03 <br /> ( ) O1 [ 1 02 1 ) 03 <br /> ( } 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 I 1 03 <br /> �( CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> EISCO:NTAINER LOCATED ON AN AGRICULTURAL FARM' ( l 01 YES ;X) 02 NO <br /> THIS FORM HAS BEEN COMPL D DER THE PENALTY PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNAT ) PHONE W/APEA CODE <br /> FOR LOCAL AGENCY USE ON <br /> A:"".INISTRATING AGENCY ,. <br /> CITY CODE COUNTY CODE <br /> 5XA U r IV -OCAU fteNUTri15 <br /> CONTACT PERSON PHONE EA_ CODE <br /> 1N PrC.Lry C'a G 1 <br /> DATE OF LAST INS ECTION IN COMPLIANCE <br /> PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> {f� ( ) O1 YES ( ) 02 NO <br /> RAGE 2 <br /> HSC04-070185 7(,10/18/85) <br />