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STATE I0 NUMBER 00000013694001 <br /> CONTAINER CONSTRUCTION <br /> E ( 1RUBBER <br /> LINED( <br /> (Xl ) OB UNKNOWN L(N 1H09 OTHER:03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) OS GLASS LINING <br /> F ( ) ol LHNASPHA LT ((1102 VINTL ( ) 03 CATHODIC PROTECTIO <br /> (X) 06TAR ORN [ 1 04 UNKNOWN ( ] 05 NONE <br /> VI PIPING <br /> EUNDERGROUND <br /> ABOVEGROUND <br /> (CHECKE <br /> APPROPRIATE•BO%(ES) ( f O1D4 PRESSURE 05 <br /> PIPE <br /> SUCTION CONCR06EUNKNOWNTRENCH 07(NONE3 GRAVITY <br /> RIATE•BOX(ES) f ( 0104 PRESSURELEOX) PE 02 05 SUCTION CONCRETE-LINED UNTRENCH 07f HOME <br /> GRAVITY <br /> VII LEAK DETECTION 05 <br /> ( ( ) 0VISUAL <br /> GROUNDWATER MONITORING NWELLS TORYf( ))D 07VPRESSURE APOR F TESTEES )f 09 NONE 10 <br /> INSTRUMENT0 OTHER: <br /> VIII CHEMICAL COMPOSITION OFATEi0 MATERIALS <br /> STORED E THISSIENIpUNDERGROUND CONTAINERS <br /> IF YOU CHECKEC YES TO :V-F YOU ARE NOT REQUIRED <br /> CURRENTLY PREVIOUSLY DELEiE CA Sft fZF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) O1 f ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> f ) Ol ( l 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> ( ) Dl ( ) 02 ( 1 03 <br /> ( 1 01 f 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> +t CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> I5 CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 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 /> PHONE W/AREA�CODE . �� r. ^/� <br /> PEP p FILIN fS NATURE ^Ty�+�gll 1`IC_ <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CO COUNTY CODE <br /> ADMINISTRATIN^ AGENCY ZPHON� ODE <br /> -,/ W/ARL'A _ �714� <br /> CCNTAG EPSON ^ -YLS�/g6 4 ( T <br /> DATE OF LAST I SPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 # <br /> f ) 01 YES f 1 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />