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• 0 STATE IO NUMBER 00000012656003 <br /> CONTAINER CONSTRUCTION <br /> N[ 11RUBBER LINED(X1 08 UNKNOWN I ) 02 ALKYD L( 1N 09 OTHERS <br /> 1 EPDXY LINING [ 1 04 PHENOLIC LINING 1 1 05 GLASS LINING <br /> E 0 <br /> F ( 1(01 POLYETHLENE WRAP <br /> ((1 VINYL <br /> OTHER: ( 103 CATHODIC PROTECTION [X1 04 UNKNOWN ( 1 05 NONE <br /> VI PIPING <br /> A ABOVEGROUND <br /> ( ( 1)104 PRESSURE LED P105 SUCTION PE 02 CONCRETE-LINED UKNOWNTR( IH 07(NONE3 GRAVITY <br /> RIATE <br /> B. UNDERGROUND PIPING' ( I O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE l ) 05 SUCTION (X) 06 UNKNOWN ) 07 NONE <br /> ( <br /> VII LEAK DETECTION <br /> ( ( 0306VISUAL <br /> GROUND(W1 02 STOCK INVETOY ATER MONITORINGNWEL LS ((11007VAPOR <br /> PRESSURESNIFF <br /> TESTWELLS X)(09 NONE05 ENSOR 1005OOTHER: <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 CASA (IF KNOWN) <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 [ ) 02 f 1 03 <br /> ( 1 <br /> 01 l ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 f ) 02 ( 7 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 Ol [ ) 02 f ) 03 <br /> ( 1 01 ( 1 02 ( ] 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 O1 YES ( ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PER AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PHONE W/AREA CODE D <br /> pERSON FILING (SIGNATURE) <br /> FOR LOCAL AGENCY USE ONLY COUNTY CODE <br /> CITY CODE <br /> AO MZ NI STRATiNG AG-c NCY <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> OF LAST INSPECTION IN COMPLIANCE <br /> TRANSACTION DATE LOCAL PERMIT ID # <br /> DATE 01EPERMIT APPROVAL DATE( 1 02 NO <br /> PAGE 2 <br /> iSC04-070185 (10/18/851 <br />