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STATE 1-0 NUMBER 00000062408001 <br />E. ( ) 01 'RUBBER LINED t ) 02 ALKYD LINING d 103 EPDXY LINING ( ) 04 PHENOLIC LINING t 1 05 GLASS LINING <br />(X) ,07 UNLINED t ) 08 UNKNOWN t );:09 OTHER. <br />F. t ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING { ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT ( )'09 OTHER' <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( } 01 DOUBLE—WALLED PIPE t }-02 CONCRETE—LINED TRENCH ( } 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE_ 4 ) 05 SUCTION { ) 06 UNKNOWN ( ),07 NONE <br />B. UNDERGROUND PIPING: ( l 01 DOUBLE—WALLED PIPE ( } 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOXtES) t ) 04 PRESSURE t } 05 SUCTION { } 06 UNKNOWN t ) 07 NONE <br />VII LEAK DETECTION <br />t-) 01 VISUAL (X) 02 STOCK INVENTORY ( } 04 VAPOR SNIFF WELLS ( ) 05 SENSOR .INSTRUMENT <br />{ 1 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST t ) 09NONE ( ) 10 OTHER: <br />VIII CHEMICAL COMPO'SITID`N 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 CA$# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />t ) 0;1 <br />( ) 02 <br />( ) 03 <br />t ) 0,1 <br />( ) 02 <br />t ) 03 <br />01 <br />( } 02 <br />(, 1 03 <br />d ) 01 <br />( ) 02 <br />d ) 03 , <br />f 1 01 <br />( ) 02 <br />( ) 03_ <br />t ) 01 <br />t ) 02 <br />( ) 03 <br />E ) 01 <br />( ) 02 <br />{ ) 03 <br />{ ) 01 <br />( ) 02 <br />t ) 03 <br />t ) 01 <br />( ) 02 <br />( 1 03 <br />(<) 01 <br />( ) 02 <br />( 1 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 />CHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSON FILING (SIGNATURE) PHONE W/AR€A CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />CONTACT PERSON PHONE W/AREA CODE <br />DATE OF LAST INSPECTION IN COMPLIANCE 1,PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />( ) 01 YES ( ) 02 NO <br />HSC04-070185 (10/18/85) <br />PAGE 2 <br />