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1�STATE ID NUMBER 00000011183001 <br /> CONTAINER CONSTRUCTION <br /> I } OI RUBBER LINED ( } 02 ALKYD LINING I 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING I 1 05 GLASS LINING <br /> (X1 07 UNLINED ( 1 08 UNKNOWN ( 1 09 OTHER <br /> v( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING I 1 03 CATHODIC PROTECTION i 1 04 UNKNOWN IX1 05 iJO1JF <br /> 1 06 TAP OR ASPHALT l 1 09 OTHER: <br /> I PIPING <br /> ABOVEGROU110 PIPING: I 1 01 DOUE•LE-WALLED PIFIE�( 1 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK. AFFFCFRIATE BOX(ES) ( } 04 FRE55URE ( 1 05 SUCTION ( 1 06 UNKNOWN I 1 07 NONE <br /> UNDERGROWID PIPING: ( 1 01�OCUBLE-WALLED PIPE ( } 02 CONCRETE-LINED TRENCH I ! 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTICN l 1 06 UNKNOWN I 1 07 NONE <br /> II LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY I 1 C4 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT - 1 <br /> ( 1 06 GRCUIID WATER MCNITORIHG WELLS f 1 C7 PRESSURE TEST ( ) 09 NONE I 1 10 OTHER; 11 <br /> III CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> -F YOU CHECYEO YES TO IV-F YOU AFE NOT PECJIPED TO COMPLETE THIS SECTION <br /> jr:ENTLY PFE%.':CUS0 DELETE CASP 1IF KNCWNi CHEMICAL (00 NOT USE COMMEFCIAL NAME ] <br /> STC?ED STC=ED <br /> ( ] 01 E 1 02 ( 1 03 <br /> ( l 01 i 1 02 ( } 03 <br /> ( 101 f 102 1103I4111111lI I I <br /> ( } 01 f 1 02 [ } 03 <br /> f ! 01 ( 1 02 I } 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> ( } 01 [ 1 02 ( } 03 <br /> t } <br /> 01 ( 1 02 ( 1 03 <br /> ( ) 01 ( 1 02 f ] 03 - <br /> ( 1 01 ( } 02 ( } 03 <br /> ( 1 01 I 1 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> 5 CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES (X) 02 NO <br /> IS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> _=SCN FILING (SI3N47URE) R�"A"A CODE <br /> OR LOCAL AGENCY USE ONLY <br /> TNISTPATINO AGENCY CIT <br /> Y CODE COUNT(' CODE <br /> OST <br /> T ^ . FHC E W/ARE CODE <br /> ° tI <br /> IJ{] 71 1 - <br /> 1''- OF LAS- -NSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TPANSAGTIDN CATS LOCAL PERMIT ID A <br /> ( 1 O1 YES ( 02 NQ <br /> PAGE 2 <br /> C04-070185 I10/1B/851 <br />