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0 • <br /> CONTAIN -R CONSTRUCTION STATE ID NUMBER 00000038443002 <br /> E• ( 1 O1 RUBBE LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( 7 05 GLASS LINING <br /> ( 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F• ( ) O1 PO LTAT OR NE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 7 04 UNKNOWN [ 1 05 NONE <br /> (X7 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND P,qJ ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> APPROPRIATE <br /> BOXES) <br /> (CHECK APPROPRIATE f ) 04 PRESSURE ( ) 05 SUCTION ( ] 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING' ( 7 01 DOUBLE-WALLED PIPE <br /> (CHECK APPROP IATE BOX(E9) ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> ( ) 04 PRESSURE (\4 05 SUCTION ( ) 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DE ECTION <br /> J ) 01 VISUAL X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( 7 05 SENSOR INSTRUMENT <br /> GRO <br /> ( ) ObUND WATER MONITORING WELLS [ ) 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: <br /> VIII CHEMIC L COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKE YES TO IV-F YOU ARE NOT REQViRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> STORED STCPED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( 1 <br /> 01 [ ) 02 f ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 7 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( 7 03 <br /> f 7 01 ( 1 02 ( 1 03 <br /> ( ) 03 ( J 02 ( ) 03 <br /> f ) 01 ( ) 0 ( ) 03 <br /> ( ) 01 f 1 02 f ) 03 <br /> [ ) 01 ( ) 02 ( ) 03 <br /> f l 01 ( ) 02 f ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FIS LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN 0iOMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FI ING G RE) K <br /> PHONE W/AREA CODE <br /> Zo'9-�23 - �80P <br /> FOR OCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY 1,/��S' <br /> vi ^` �'^ � /� CITY CODE COUNTY CODE <br /> CONTACT PERSON <br /> 7 F r (4k(> Q PHONE W/AREA CODE <br /> DATE OF LASTINSPECTION IN COMPLIANCE IA NCE _ <br /> �D ( ) O1 YES ( ) 02 NO PERMIT APPROVAL DATE TRANSACTION DATE <br /> F6 <br /> LOCAL PERMIT ID # <br /> SC04-070185 (10/18 5) <br /> PAGE 2 <br />