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.e. <br />STATE I0 NUMBER 00000013932005 <br />CONTAINER CONSTRUCTION <br />E. ( 1 01 RUBBER LINED f ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />( 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br />( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ). 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />(. ABOVEGROUND PIPING: f ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN Ot'r 07 NONE <br />{. UNDERGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( 7 01 VISUAL (-W02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT <br />( l 06 GROUND WATER MONITORING WELLS L\4-07 PRESSURE TEST 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 REQUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CASA (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />l 7 01 <br />( ) 02 <br />( ) 03 <br />f ] 01 <br />f ) 02 <br />( ) 03 <br />f l 01 <br />f ) 02 <br />( ) 03 <br />f 1 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( 1 03 <br />f ) 01 <br />f 1 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />f ) 03 <br />f l 01 <br />f 1 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( 1 O1 <br />f ) 02 <br />( ) 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 BE <br />CEPSON FILI <br />FOR LOCA <br />ADMINISTRATE <br />CONTACT PERSON <br />UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />AGENCY USE ONLY <br />AGENCY <br />CODE <br />PHONE W/AREA CODE <br />CODE <br />(DATE OF LAST INSPECTION PIN COMPLIANCE( 1 02 NO (PERMIT APPROVAL DATE (TRANSACTION DATE (LOCAL PERMIT ID R <br />HSC04-070185 (10/18/85) <br />\a*f <br />PAGE 2 <br />