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STATE ID NUMBER 00000001392004 <br /> AINER CONSTRUCTION <br /> UBBER LINED ( l 02 ALKYD LINING ( ) 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f,•7 UNLINED [ ) 0$ UNKNOWN ! 1 09 OTHER <br /> )LYETHLENE WRAP f ) 02 VINYL WRAPPING ! 1 03 CATHODIC PROTECTION { ) 04 UNKNOWN (X)' 05 NONE <br /> TAR OR ASPHALT ( ) 09 OTHER. <br /> AG <br /> ,UNO PIPING. ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> APPROPRIATE BOX(ES) ( -1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ! 7 07 NONE <br /> ROUND PIPING ( ) 01 DOUBLE-WALLED PIPE i 1 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> APPROPRIATE BOX(ES) (X) 04 PRESSURE t ) 05 SUCTION ( 3 06 UNKNOWN ! 1 07 NONE <br /> EAK DETECTION <br /> )i VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 06 GROUND WATER MONITORING WELLS { ) 07 PRESSURE TEST ! l 09 NONE ( ) 10 OTHER- <br /> iI 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 /> JRRENTLY PR-EVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( l 01 ( ) 02 ( ) 03 <br /> [ 1 O1 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( l 03 <br /> ! ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> t ) 01 f ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( ) <br /> 01 t l 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l 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/AP.EA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> N3MINISTRATING AGENCY CITY CODE COUNTY CODE <br /> -- P PHONE ✓ yArQ� <br /> T INSPECTION N CO PLIANCE <br /> JRERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> l ) 01 YES ( ) 02 <br /> PAGE 2 <br />