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STATE IB NUMBER 00000043411002 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( l 02 ALKYD LINING (X) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> t ) 07 UNLINED C ) 08 UNKNOWN ( ) 09 OTHER= <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION (X) 04 UNKNOWN t ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER.* J <br /> VI PIPING <br /> A. ABOVEGROUND PIPING- [ ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 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) t ) 04 PRESSURE (X) 05 SUCTION C ) 06 UNKNOWN [ ) 07 NONE <br /> VII LEAK DETECTION <br /> { ) 01 VISUAL (XI 02 STOCK INVENTORY t 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> i ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( 1 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 STORED <br /> i 1 01 C ) 02 ( ) 03 <br /> t 1 <br /> 01 C ) 02 ( 1 03 <br /> ( ) 01 [ 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 C ) 02 ( ) 03 <br /> ( ) 01 C l 02 [ 1 03 <br /> ( l 01 ( ) 02 C 1 03 <br /> ( ) 01 ( ) 02 t ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 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 EEN COMPLETED UNDE HE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEO Fi a iS NjTUR 1 PHONE W/AREA CODE <br /> 2 47 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGEN2Y CITY CODE COUNTY CODE <br /> CONTACT PEPSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 4 <br /> 01 YES C 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />