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STATE ID NUMBER 00000031535001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 101 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> !xl 07 UNLINED of W08 UNKNOWN ( ) 09 OTHER: <br /> F. l 1 01 POLYETHLENE WRAP l ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION 4K-T 04 UNKNOWN (AV 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING= ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ! 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( l 05 SUCTION ( l 06 UNKNOWN ba) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH l 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL 02 STOCK INVENTOR'L ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUNI*WATER Ml0 WELLS f ) 07 PRESSURE TEST ( 1 09 NONE ( l 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 CAER (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED _ <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> f 1 <br /> 01 ( 1 02 ( ) 03 <br /> l ) O1 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 f 1 02 ( ) 03 <br /> f ] 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? [ 1 01 YES (X1 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 /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> a <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AOlNC / CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSP CTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 1( <br /> 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />