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STATE ID NUMBER 00000008376002 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( 1 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( ) O1 POLY ETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN l ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER- <br /> VI PIPING <br /> PE <br /> LEE <br /> •BOX(ES] ( ( 0104 PRESSUESSURE 05 <br /> P105 SUCTION PE 02 CONCRETE-LINED 06UNKNOWNTR(N)H 07(NONE <br /> GRAVITY <br /> :RIATE BOX(ES) ( ( 0104 UBLE-WALLED P1PRESSURE t 05 SUCTION PE 02 CON'R E06E�LINED tKNOWNTREN�H 07(NONE3 GRAVITY <br /> CK <br /> VII LEAK DETECTION <br /> INTRUMENT <br /> ( ( VISUAL <br /> GROUND( ) 02 STOCK WATER MONITORING NWELLS (( 11007VAPOR <br /> PRESSURESNIFF <br /> TESTWELLS <br /> Xi( 05 09 NONESENSOR 10SOTHER: <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 /> CUP.PENTLY PP.EVIOVSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) 01 ( l 02 ( ) 03 WASTE WATER (PROCESS OR INDUSTRIAL) <br /> ( ) 01 ( l 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 [ 1 02 ( ) 03 <br /> ( 1 01 ( ) 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) �, / !./1 VL <br /> FOR LOCAL AGENCY USE ONLY <br /> ?� CITY CODE COUNTY CODE <br /> ADMINISTRATING AGEN Y ` / <br /> CONTACTTJ1fl�LPP PERSON <br /> l.+ PHONE W/AREA CiO -� <br /> 661 Z <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 30_� 01 YES ) 02 NO <br /> (/ PAGE 2 <br /> HSC04-070185 (10/18/85) <br />