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STATE 10 NUMBER 0.0000062408003 <br />E. 01 RUBBER LINED ) 0L2 ALKYD LINING ( ) 03 EPDXY LINING 04 PHENOLIC LINING 05 GLASS LINING <br />(X) 07 UNLINED 08 UNKNOWN 09 OTHER: <br />F. 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION 04 UNKNOWN (X) 05 NO <br />06 TAR OR ASPHALT 09 OTHER* <br />Vi PIPING <br />A. A50VEGROUND PIPING: 01 DOUBLE -WALLED PIPE 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) t D 04 PRESSURE 05 SUCTION I ) V6 UNKNOWN 07 NONE <br />B. UNDERGROUND PIPING: 01 DOUBLE -WALLED PIPE 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) 04 PRESSURE 05 SUCTION 06 UNKNOWN J ) 07 NONE <br />VII LEAK DETECTION <br />01 VISUAL (X) 02 STOCK INVENTORY t l 04 VAPOR SNIFF WELLS ) 05 SENSOR INSTRUMENT <br />) 06 GROUND WATER MONITORING WELLS 07 PRESSURE TEST ( 09 NONE ( ) IDIOT HER: I <br />VIII CHEMICAL COMPOSITION Of MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CASH (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />01 <br />( ) 02 <br />( ) 13 <br />01 <br />( ) 02 <br />( 1 03 <br />01 <br />( ) 02 <br />( ) 03 <br />al <br />( ) 02 <br />1 1 03 <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( 1 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LIS -TING FOR 'POSSIBLE SYNONYMS <br />LI S TAIINIER LOCATED ON AN AGRICULTURAL FARM? 01 YES (X) 02 NO <br />CHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO TIRE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSON FILING (SIGNATURE) E <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />CONTACT PERSON PHONE W/APEA CODE <br />DATE Of LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID <br />01 YES 02 NO <br />HSC04-070185 (10/18/85) PAGE 2 <br />