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STATE I0 NUMBER 00000014331002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( 102 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN l 1 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 7 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: [ ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE f 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 'j ) 01 VISUAL f 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS W(9 05 SENSOR INSTRUMENT <br /> I ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST (,�)_09 NONE t ) 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 (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> I l 01 ( ) 02 ( 1 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 f ) 03 <br /> f 7 Ol ( ) 02 ( ) 03 <br /> l ) 01 ( ) 02 f ) 03 <br /> ( 1 Ol ( ) 02 ( 7 03 <br /> ( ) Ol ( ) 02 f ) 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 f l 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 /> P R N F ( ZGN TURE1 PMO W/AREA CODE <br /> 57-7,/- 37 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADM NI TP.ATINO AGENCY CITY CODE COUNTY CODE <br /> CONT T PERSON P ONE W/AREA CODE <br /> a L7- <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YCS ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> 1/ 1./ <br />