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V STATE I0 NUMBER 00000018686001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 7(01 078UNLINEDBER ED(X) 080UNKNOWN LINING 1H09 OTHER3 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> F. ( 7(0) 06LTARHORNE WRAPASPHALT ((1l 2 VINYLWRAPPING ( ) 03 CATHODIC PROTECTION (X1 04 UNKNOWN ( l OS NONE <br /> VI PIPING 02 <br /> A. ABOVEGROUND PIPING= ( 1 O1 DOUBLE-WALLE PIPE07 <br /> SUCTION CONCRE06ETY <br /> KNOWNTR(N 1H 07(NONE3 GRAM <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE <br /> B. UNDERGROUND PIPING ( 1 O1 DOUBLE-WALL PI05 SUCTION 02 02 CO(X 1R 06ET EUNIN <br /> KNOWNTREN�W 07(NONE <br /> GRAVITY <br /> (CHECK APPROPRIATE BOX(ES1 ( ) 04 PRESSURE <br /> VII LEAK DETECTION <br /> + ` 010VISUAL 02 6 GROUND WATER STOCK INVENTORY <br /> (f 71007VPRESSUREAPOR SNIFF <br /> TESTWELLS(X)(09 NONERIN <br /> ENSOR lOSOTHERNT <br /> U AREREQUIRED UNDERGROUND CONTAINERS <br /> VIiFHEMILsOPOSITION OF MATERIALS IN <br /> YOU D EDeTSI <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( ) O1 ( 7 02 f 1 03 <br /> 1 1 O1 ( 7 02 .. f ) 03 <br /> f l 01 f l 02 ( 1 03 <br /> [ 1 Ol ( 1 02 ( 1 03 <br /> ( ) di ( ) 02 f 7 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 O1 ( 7 02 f ). 03 <br /> f l 01 f ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( l 02 ( 1 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 /> PERSON FILING (SIGNATURE) 0 PHONE W/AREA CODE <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 INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />