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• STATE ID NUMBER 00000037593002 <br /> CONTAINER CONSTRUCTION <br /> E. ( 7 O1 RUBBER LINED ( EO2KYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED ( ) OWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRA2 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION04 UNKNOWN f ) 05 NONE <br /> ( ) 06 TAR OR ASPHA09 OTHER: <br /> VI PIPING <br /> A ABOVEGROUND <br /> BOX(ES) ( ( 0104OPRESSURELEO( PIPE <br /> 05 SUCTION CONCRETE-LINED <br /> UNKNOWNTRI 7H 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> B UNDERGROUND <br /> PRIATE•BOX(ES) ( ( 01040PRESSURELEU )I05 SUCTION CONCRETE-LINED 06UNKNOWNTRENCH <br /> 07( 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> ( ( ) VISUAL <br /> ) 02 STOCK WATER MONITORINGNTORYWELLS (( 11007VAPOR <br /> PRESSURESNIFF <br /> TESTLLEN <br /> (X)(09 NONE ( 1 INSTRUMENT <br /> 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> :F YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) 01 { 1 02 ( ) 03 <br /> ( 101 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( ) 01 f 1 02 ( ) 03 <br /> ( I <br /> 01 l ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f ) 01 ( 7 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? (X) 01 YES ( ) 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 (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGEtiCY <br /> CITY CODE COUNTY CODE <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> GATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) O1 YES ( 1 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />