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STATE ID NUMBER 00000054749004 <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 7 01 POLYETHLENE WRAP ( ] 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( 7 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> 02 <br /> A (CHECKRA PROPRIATE.BOX(ESI 1 ( 0104 RESSURELEU PI05 SUCTION DOLE-WALPECONCR 06EUNKNOWNTRfNCH 071 NONE3 GRAVITY <br /> B. (CHECKRA APPROPRIATE BOX(ES) 1 ( 01040 PRESSURE 05 <br /> P105 SUCTION CION 1R 06EUNKNOWN�EN 1H 071 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> TRENT <br /> ( ( VISUAL <br /> GROUND WATER MONITORINGNWELLS 1()1007VAPOR <br /> PRESSURESNIFF <br /> TEST (X)WELLS <br /> S <br /> 1 02 STOCK X)109 NONE 10 <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 /> CURP.ENTLY PREVIOUSLY DELETE CASAj(IFKNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) 01 ( ) 02 ( ) 03 INDUSTRIAL SEWAGE WASTE <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> 1 1 Ol ( ) 02 ( 1 03 <br /> l ) <br /> 01 E l 02 ( ) 03 <br /> l ) O1 ( 7 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 f ) 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 UN ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATUR PHONE W/AREA CODE <br /> FOR LOCAL AGENCY US ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/ARCA CODE <br /> DATE OF LAST INSPECTION INCOMPLIANCE PERMIT APPROVAL DATF TRANSACTION DATE LOCAL PERMIT ID 11 <br /> ( ) O1 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />