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J _ • • STATE ID NUMBER 00000048936003 <br /> CONTAINER CONSTRUCTION <br /> E. ( 101 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER <br /> F. f ) 01 POLYETHLENE WRAP ( 7 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A (ABOVEGOUND CHECKR APPROPRIATE BOX(ES) ( f 0104DOUBLE-WALLED( PIPE 02) 05 SUCTION CONCRETE-LINED( ) 06UNKNOWN (TRENCH 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> B <br /> (CHECKAPPROPRIATEPIPING:BOX(ES) ( ( 0110 PRESSURE 05 <br /> PIPE <br /> SUCTION C(X) 06EUNKNOWNTR`N IH 07[ 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> NSTRUMENT <br /> ( ` <br /> 01 VISUAL ) 02 STOCK <br /> MONITORING NTORY WELLS [( )1007VAPOR PRESSUREFTESTLLSX)( 05 09 NONEENSOR 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> :F YCV CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CV4FENT LY PREVIOUSLY DELETE CAS# (IP KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( l 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( 1 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 [ ) 02 [ ] 03 <br /> ( ) 01 ( ) 02 [ 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ] 03 <br /> ( 1 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 /> PHONE W/AREA CODE D <br /> PERSON FILING (SIGNATURE) <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> ADMINISTRATING AGENCY <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> PAG <br /> HSC04-070185 (10/18/85) <br />