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• STATE ID NUMBER 00000040220001 <br /> CONTAINER CONSTRUCTION <br /> )(X) RUBBER <br /> LINED( ) ) 02 ALKYO <br /> LINING <br /> 09 OTNER3 EPDXY LINING <br /> ( ) 04 PHENOLIC LINING ( ] 05 GLASS LINING <br /> 07 <br /> NED <br /> )(0LHNE WRAP (())02 VINYL OTHER: ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ) 06TARORASPHALT <br /> PIPING <br /> ( 1 O1 DOUBLE-WALLED PIPE t 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> ABOVEGROUND PIPING ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br />(CHECK APPROPRIATE BOX(ES) <br /> UNDERGROUND PIPING' ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (Xl 05 SUCTION [ ) 06 UNKNOWN ( ) 07 NONE <br /> I LEAK DETECTION <br /> ( O1 6VSUALIGROUNDTRUMENT <br /> (WA) 02 STOCK INVETOYTER MONITORINGNWELLS (())007V PRESSUREF TESTLL EX)(09 NONEENSOR 10 OTHER* <br />:II 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 /> iR RENTLY PREVIOUSLY DELETE CASK (IF KNOWN) <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />.TOPED STOPED <br /> 01 f ) 02 ( ) 03 <br />[ ) 01 ( l 02 ( ) 03 <br />( 1 01 ( ) 02 ( ) 03 <br />( ) 01 l ) 02 ( ) 03 <br />( ) <br /> 01 ( 1 02 ( ) 03 <br />( 1 01 ( ) 02 ( ) 03 <br />( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ] 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> L CODE LISTING FOR POSSIBLE SYNONYMS <br /> I CHECK STATE BOARD CHEMICA <br /> IS 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 WMAREAO CODE GET IS TRUE AND CORRECT. <br /> PHO <br /> PERSON FILING (SIGNATURE) <br /> FOR LOCAL AGENCY USE ONLY CITY CODE COUNTY CODE <br /> ADMINISTRATING AGENCY <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> PERMIT APPROVAL DATE <br /> TRANSACTION GATE LOCAL PERMIT I0 >< <br /> DATE OF LAST INSPECTION IN OjO 01LYESCE( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) • <br />