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CONTAINER CONSTRUCTION <br /> STATE ID NUMBER 00000037907004 <br /> E. ( J 01 RUBBER LINED ( ) 02 ALKYD LINING <br /> (X) 07 UNLINED ( 7 08 UNKNOWN f ) 03 EPDXY LINING <br /> ( ) 09 OTHER: ( 7 04 PHENOLIC LINING <br /> F. ( ) O) 06 TAR HLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION tXl 04 UNKNOWN OS GLASS LINING <br /> ( 7 06 TAR OR ASPHALT ( ) 09 OTHER:VI PIPING ( 7 OS NONE <br /> A- ABOVEGROUND PIPING: <br /> (CHECK APPROPRIATE BOX ES) ( ) O1 4OPR S URWALLED PIPE <br /> ) 04 PRESS ( ) 02 CONCRETE-LINED TRENCH 03 GRAVITY f ) <br /> B. UNDERGROUND PIPING: ( E ( ) 05 SUCTION ( ) 06 UNKNOWN <br /> (CHECK APPROPRIATE BOX(ES) ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH 07I NONE03GRAVITY <br /> IX1 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN <br /> VII LEAK DETECTION ( ) 07 NONE <br /> ( 7 01 VISUAL (WA 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 7 06 GROUND WATER MONZ70RING WELLS ( ) 07 PRESSURE TEST <br /> VIII CHEMICAL COMPOSITION ( ) 09 NONE ( ) 10 OTHER: <br /> IF YOU CHECKED YES TO IV-F YOU ARE_NOT R QATE TO COMPLETE THIS SECTION <br /> RIALS STORED IN UNDERGROUND <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CONTAINERS <br /> STOPED STOPED <br /> ) O1 ( ) 02 ( ) 03 CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 f ) 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> ( ) Ol f 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (X) 02 NO <br /> AIS FORM HAS BEEN COMPLETED UNDER THE P[NALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGEr IS TRUE AND CORRECT. <br />:EPSON FILING (SIGNATU-E1 <br /> PHONE W/AREA CODE <br />.OR LOCAL AGENCY USE ONLY <br /> ADMINISTRATIN3 .AGENCY <br /> CITY CODE <br /> COUNTY CODE <br /> CONTACT PERSON <br /> PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANC PERMIT APPROVAL DATE <br /> ( 1 O1 YE5 02 NO TRANSACTION DATE <br /> LOCAL PERMIT ID # <br /> HSC04-070185 (10/18/851 <br /> PAGE 2 <br />