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STATE 10 NUMBER 00000051098001 <br />E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />{ ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br />F. (X) 01 POLYETHLENE WRAP { ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION t d 04 UNKNOWN d ) 05 NONE <br />( ) 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: ( d 01 DOUBLE—WALLED PIPE ( )-02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) Q<)'04 PRESSURE 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE ,( 10 OTHER: /-(he C <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 CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />t 3 02 <br />( ) 03 <br />t ) 01 <br />( J 02 <br />( 3 03 <br />f ) 01 <br />t J 02 <br />( J 03 <br />t'}01 <br />t )02 <br />t )03 <br />(i 01 <br />( } 02 <br />( d 03- <br />t ) 01 <br />( l 02 <br />( ) 03 <br />( 3 01 <br />( ) 02 <br />( ) 03 <br />t J 01 <br />( ) 02 <br />( ) 03 <br />( ) Ol <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />t } 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 BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PER0 FILING (SIG' E) PHONE W/AREA CODE <br />cp <br />LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCYCITY CODE COUNTY CODE <br />CONTACT 'PERSON PHONE W/AREA CODE <br />DATE OF LAST INSPECTION INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID it <br />( ) 01 YES ( ) 02 NO <br />HSC04-070185 (10/18/85) <br />PAGE 2 <br />