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STATE IO NUMBER 00000048861004 <br /> CONTAINER CONSTRUCTION <br /> EF (X) <br /> O1 RUBBER LINED l ) 02 ALKYD LINING f ) 03 EPDXY LINING ( l 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION04 UNKNOWN ( ) 05 NONE <br /> ) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A ABOVEGROUND <br /> BOX(ES) ( f 0104 PRESSURELED PIPE 02 <br /> SUCTION CONCRETE-LINED <br /> LNiKNOWNTR(N) 07 (NO3 GRAVITY <br /> NE <br /> B. UNDERGROUND <br /> OPRIATE• <br /> BOX(ES) f 444 04 PRESSURE01 LED PIPE <br /> 05 SUCTION CONCRETE-LINED 06UNKNOWNTRfN)H 07 HOME <br /> S GRAVITY <br /> HONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL f ) 02 STOCK INVENTORY ( ] 04 VAPOR SNIFF WELLS l ! 05 SENSOR INSTRUMENT <br /> 1 ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( 1 02 t ) 03 <br /> ( ) O1 ( 1 02 ( ) 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> ( 7 01 ( ) 02 ( 1 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 [ 1 02 ( ) 03 <br /> l ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 f ) 02 ( 1 03 <br /> ( ) 01 f ) 02 f ) 03 <br /> ( 1 <br /> 01 - ( ) 02 ( ) 03 <br /> • CHECK STATE BOARD.CMEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM H BEEN COMPLETED UqPER TH PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON F 0 (SIGN Ll [ HONE W/AREA COD! <br /> 3 3 <br /> FOR VOCAL AGENCY USE ONLY <br /> ADMI NISTRATINO AGEI:CY CITY CODE COUNTY CODE <br /> �T 3 <br /> CONTACT PERSON PHONE W/AREA CODE $��� <br /> G+41t2Y a" <br /> DATE OF LAST INSPECTION IN COMPLIANOC PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) O1 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />