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0 STATE IO NUMBER 00000008376004 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 7 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A (CHECK APPROPRIATE BOX(ES) ( ( 0104 PRESSURELEO P205 SUCTION CONCRETE-LINED( ) 06UNKNOWNTR(N 3 GRAVITY <br /> � <br /> H 07(NONE <br /> B (CHECK APPROPRIATE BOX(ES) ( ( 0104DOUBLE-WALLED f )I05 SUCTION CONCRETE-LINED 06UNKNOWNTREN;H 07t 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> TRENT <br /> (%) 0106VISUAL <br /> GROUND(WATER MONITORINGNWELLS (( 1)007VAPOR <br /> PRESSURESNIFF <br /> TESTWELLS )( 05 S <br /> 1 02 STOCK 09 NONE <br /> 10OTHER: <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) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> [ ) 01 ( 1 02 ( 1 03 <br /> ( ) 01 f 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 t ) 02 ( ) 03 <br /> ( 1 01 f ). 02 ( ) 03 <br /> ( ) <br /> 01 t ) 02 ( ) 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> ,( ) 01 ( ) 02 ( ) 03 <br /> ( l O1 f l 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 9 v 3-r6 6 I- <br /> RE'r.50N FILING (SIGNATURE < <br /> FOR LOCAL AGENCY USE ONLY <br /> IST " CITY CODE COUNTY CODE <br /> �AOMINIST=' NG AGENCY u�� <br /> CONTACT PER N PHONE W/AREA CODE 2i <br /> 7,4 9 -S <br /> DATE ,L ST IN P GF CTZON IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> � <br /> . /`� ( 1 01 YES ( ) 02 NO <br /> VV VV PAGE 2 <br /> -HSC04-070185 (10/18/85) <br /> is • <br />