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• <br /> STATE ID NUMBER 00000011758005 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 Ol RUBBER LINED ( 1 02 ALKYD LINING ( J 03 EPDXY LINING ( 3 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER. <br /> F. ( l 01 POLYETHLENE WRAP ( ] 02 VINYL WRAPPING ( } 03 CATHODIC PROTECTION t } 04 UNKNOWN ( 1 05 NONE <br /> (X) 06 TAR OR ASPHALT ( } 09 OTHER' <br /> VI PIPING <br /> A. ABOVEGROUND PIPING= ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 FRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ] 04 PRE55URE (X) 05 SUCTION ( ] 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> LX-1' 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS 0f 07 PRESSURE TEST ( 1 09 NONE ( ) 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 /> CL,'RRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STOPED -- - <br /> [ 1 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> i 1 01 ( 1 02 ( ) 03 <br /> i 1 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( } 03 <br /> ( ) <br /> 01 ( ) 02 ( } 03 <br /> i ) 01 ( 1 02 ( } 03 <br /> ( } 01 ( D 02 ( 1 03 <br /> f ) <br /> 01 ( 1 02 ( ) 03 <br /> t } 01 ( 1 02 t 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS__C_ <br /> ONTAI (ER LCCATED 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 (SIG URE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY <br /> CITY CODE COUNTY CODE <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE <br /> PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID <br /> t ) 01 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (lC/18/85) <br />