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• • STATE ID NUMBER 00000021890001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 O1 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (XI 08 UNKNOWN ( ) 09 OTHER: <br /> F. f l O1 POLYETHLENE WRAP l ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ('X* 04 UNKNOWN ( ) 05 NONE <br /> Lo 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION l ) 06 UNKNOWN [ ) 07 NONE <br /> B UNDERGROUND <br /> BOXES) ( ) 0104 PRESSURE f,IPE 02 05 SUCTION CONCRETE-LINED <br /> UNKNOWNTRENCH <br /> 07I NONE <br /> GRAVITY <br /> VII LEAK DETECTION <br /> HH 0106IGROUNO(WATER MONZTORINGNWELLS (( 11007VAPOR PRESSUREFTESTLLS 1(09 NONE05 ENt 1 10INSTRUMENT <br /> OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED 'IES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STC-ED <br /> f l <br /> 01 ( ) 02 ( ) 03 <br /> f ) O1 ( 1 02 ( ) 03 <br /> ( ) OL ( ) 02 ( ) 03 <br /> ( ) 01 f 1 02 f ) 03 <br /> ( ) 01 ( ] 02 ( 1 03 <br /> ( J 01 ( 7 02 ( 1 03 <br /> f ] <br /> 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 7 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 f ) 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 CO LETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON I IN IGNAT PHONE W/A P. A CODE _O q O <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATIN3 AGENCY <br /> CITY CODE ���COUNTYDE <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT SO # <br /> ( > 01 YES ( 1 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />