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STATE IO NUMBER 00000059367004 <br /> CONTAINER CONSTRUCTION <br /> E ( )(X1 ol RUBBER LINED( ) 08 UNKNOWN LINING <br /> 09 (1 03 EPDXY LINING <br /> f l 04 PHENOLIC LINING ( ] 05 GLASS LINING <br /> 07 <br /> NED <br /> F. ( ) 01 POLYETHLENE WRAP [ ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br /> IX) 06 TAR OR ASPHALT ( 1 09 OTHER( <br /> VI PIPING <br /> A (CHECKR APPROPRIATE: <br /> BOX(ES) ( ( O1 DOUBLE-WALPE 02 <br /> RESSRELED )I05 SUCTION CONCRETE-LINED 06E 3 GRAVITY <br /> UNKNOWN <br /> 07(NONE <br /> B (CHECKR APPROPRIATE•BOX(ES) ( f 0104 DOUBLE-WALLED RIFE <br /> 05 SUCTION CONCRETE-LINED 06UNKNOWNTR`N 1 3 GRAVITY <br /> 07f NONE <br /> VII LEAK DETECTION <br /> ( i O1 TRENT <br /> (X) 02 STOCK <br /> INVENTORY <br /> (()1007VAPOR <br /> PRESSURE SNIFF <br /> S <br /> VSUAL TEST WELLS <br /> )(09 NONE 10 05 SENSOR <br /> 10OTHER: <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 /> rCURRENTLY PREVIOUSLY DELETEiCAS# l.IFKNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> D STORED <br /> 1 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> 01 f ) 02 f ) 03 <br /> ! 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 1 ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 f 102 ( ) 03 <br /> ( ] 01 ( l 02 ( ) 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' SON ( ATURE) PHONEWAREAODE// / <br /> ZE �f o6 Z0Y/ <br /> FOR LOCAL AGENCY USE ONLY <br /> ADM Z�{I STRATIN AGENCY CITY CODE COUNTY C009 <br /> {✓' l lC� �J <br /> CONT i PERS PHO E W/AREA CODE <br /> 6- <br /> DATE OF LAST INSPECTION IN COMPLIANC! TRANSACTION DATE LOCAL PERMIT IO # <br /> f ) 01 YES t ) 02 NO PERMIT APPROVAL DATE <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> �\ 1 <br />