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STATE 1D NUMBER 00000405724441 <br /> CONTAINER CONSTRUCTION _ <br /> E. <br /> RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t 1 04 PHENOLIC LINING d 1 05 GLASS LINING <br /> 07 UNLINED (X) 08 UNKNOWN t ) 09 OTHER; <br /> POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> 06 TAR OR ASPHALT ( ) 09 OTHER. — <br /> VI PIPING <br /> A ABOVEGROUND <br /> BOX(ES) ( ( ) 0440PRESSURELED ) 05 SUCTION CONCRETE—LINED( ) 06UNKNOWNTRENCH 07 NONE <br /> GRAVITY <br /> PIPE 02 NE <br /> B. UNDERGROUND <br /> BOX(ES) ( (X0)1040PRESSURELE� 1105 SUCTION CONCRETE—LINED <br /> UNKNOWNTR(NCH07 NONE <br /> GRAVITY <br /> E <br /> VII LEAK DETECTION <br /> t ) O1 VISUAL ( ) 02 STOCK INVENTORY i l 04 VAPOR SNIFF WELLS d l 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF Y'OU CHECKED YES TO IV-F YCU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (DO NOT USE CCMMEPCIAL NAME) <br /> STOPED S70PED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> i l <br /> 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> f ) 01 ( 1 02 ( ) 03 <br /> ( ) OI ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( 1 01 t ) 02 ( l 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( l 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER�LOCAT�EOONAN AGRICULTURAL FARM'; ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANO, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PHONE W/AREA CODE <br /> EpEFS:01S4FILIN7(SIGNhlTURE) <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY" CODE <br /> ADMINISTRATING AGENCY <br /> PHCNE W/AREA CODE <br /> CONTACT PERSCN <br /> DATE OF LAST INSPECTION IN COMPLIANCE <br /> PERMIT APPROVAL DATE TRANSACTION D.47E LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br /> 0 <br />