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• 0 STATE IO NUMBER 00000012656001 <br /> CONTAINER CONSTRUCTION <br /> E ( )(01 RUBBEUNLINED LINED(X l OB UNKNOWN LINING03 <br /> OTHER3 EPDXY LINING ( ) 04 PHENOLIC LINING ( 7 05 GLASS LINING <br /> 07 <br /> F ( l(01 POLYETHLENE WRAP <br /> (()102 VINYLWRAPPING ( ) 03 CATHODIC PROTECTION (Xl 04 UNKNOWN ( ) 05 NONE <br /> VI PIPING 02 <br /> A (CHECKRAPPROPRIATE.BOX(ESl ( ( 0104 UBLE-WALLEPRESSURE D PPE SUCTION CON(X)CRETE-LINED 06UNKNOWNTREN�H 07(NONE3 GRAVITY <br /> B. (ICHECKR APPR PRIATE•BOX(ES) ( ( Ol 4 PR€SSURELED II05 SUCTION CON'R 06EUNKNOWNTR((J 1 07( 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> ( ( Ol 6VSUALIGROUND(WA) 02 STOCK TER MONITORINGNWELLS ((11D 07VAPOR PRESSUREFTESTLLSX)(09 14ONEENSOR 10SNT <br /> OTHER <br /> VIII CHEMICAL <br /> EICALCOMPOSITION OFMoSeTORED IN UNDERGROUND CONTAINERS <br /> rEREQUIRED TsE =D <br /> mi <br /> LY PPE�IOUSLY DELETE CAS# (IF KNOWNI <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> 1 Ll <br /> STORED <br /> ( ) 02 ( ) 03l ( 1 02 [ ) 031 ( ) 02 ( ) 031 ( l 02 ( ) 03l ( ) 02 ( 1 03l ( ) 02 ( ) 031 ( ) 02 ( 1 031 ( ) 02 ( ) 031 ( ) 02 ( ) 031 [ ) 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 UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PHONE W/AREA CODE <br /> PERSON FILING (SIGNATURE) <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> ADMINISTRATING AGENCY <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE Of LAST INSPECTION IN COMPLIANCE <br /> PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 1D # <br /> ( ) O1 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />