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STATE ID NUMBER 00000021985007 <br /> CONTAINER CONSTRUCTION <br /> E ( 1(X1 01 RUBBEUNLINED LINEDI ) 08 UNKNOWN LINING <br /> OTHERS EPDXY LINING f 1 04 PHENOLIC LINING 05 GLASS LINING <br /> f 1 <br /> 07 <br /> F. Y_) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> Ob TAR OR ASPHALT f ] 09 OTHER: <br /> VI PIPING <br /> A ABOVEGROUNDATE <br /> ( ( 01 <br /> 0DOUBLE-WL _WALLED PIPE <br /> 4 PRESSURE i ) 05 SUCTION CON 1R 06EUNKNOWNTRENCH07(NONE <br /> 3 GRAVITY <br /> B UNDERGROUND <br /> A�PROPRIATE•BOX<E37 ( PE <br /> (XI D01 ) PRESSURELEO P105 SUCTION 02 CONCRETE-LINED <br /> UNKNOWNTRENCH <br /> 07(NONE3 GRAVITY <br /> VII LEAK DETECTION <br /> INSTR <br /> ENT <br /> fX( ) VISUAL 06 GROUNDWATER MONITORING WELLS) 02 STOCK INVENTORY (f ))D 07VAPOR PRESSUREFTESTLLS( 1(09 NONE05 ENSOR 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 PRE'JIOJSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) Ol ( 1 02 ( ) 03 <br /> ( 1 01 f ) 02 ( ) 03 <br /> ( ] 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 f 1 02 ( ) 03 <br /> f 1 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 l 1 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATEDDN AN AGRICULTURALFARM? ( ) 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 /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> D <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID A <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />