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y • STATE IO NUMBER 00000052297001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RU�LINED02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNKNOWN l ) 09 OTHER <br /> F. f ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A (ABOVEGOUND CHECKRAPPROPRIATE•BOX(ES) ( ( 0104 PRESSURELEO P105 SUCTION CONCRETE-LINED 06UNKNOWN�(N)H 3 GRAVITY <br /> 07(NONE <br /> B UNDERGROUNDCK APPROPRIATEIPING:BOX(ES1 ( ( 0104 PRESSURE ) OS SUCTION CONCRETE-LIKED( 106UNKNOWN <br /> TRfN7H 07(NONE <br /> 3 GRAVITY <br /> VII LEAK DETECTION <br /> ENT <br /> ( ( <br /> 01 VISUAL OUND(W1 02 STOCK ATER MONITORINGWELLSLB ((X)007 PRESSWRESNIFF <br /> TESTWELLS )(09 NONEENSOR INSTR10 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 /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 f ) 02 ( ) 03 <br /> 1 <br /> 01 ( 1 02 ( 1 03 <br /> ( J 01 ( ) 02 ( 1 03 <br /> ( ] 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON A�AGRICULT�URALFARM?�( ) �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 /> r 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 PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 # <br /> ( ) O1 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />