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STATE ID NUMBER 00000009092001 <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 /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLEHE WRAP ( ] 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A (CHECK APPROPRIATE BOX(ES) ( ( ) 04 PRESSURELE(y) 05 SUCTION CONCRETE-LINED( 06UNKNOWNTR( ) 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> B ()CHECKRAPPROPRIATE•BOXES) (( 0104 PRESSUREDOUBLE-WALLED <br /> (X)105 SUCTION CONCRETE-LINED <br /> UNKNOWNTRENCH 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> ( ) O1 VISUAL (X7 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> "� ( ) Ob GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER: <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 /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( 7 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( > 02 ' ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( 7 01 ( 1 02 ( 1 03 <br /> ( 1 <br /> 01 f ) 02 ( ) 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( ) <br /> 01 t ) 02 ( ) 03 <br /> ( l <br /> 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 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 /> p NG ( ON PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> f ) <br /> 01 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />