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STATE ID NUMBER 00000002794003 <br /> CONTAINER CONSTRUCTION <br /> E) Ol <br /> 01 NLINEDED( ) 08 UNKNOWN L(N)N09 OTHER3 EPDXY LINING ( ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> ETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION f 1 04 UNKNOWN (X) 05 NONE <br /> AR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. (CHECKRAPPROPRIATEPIPING: <br /> BOX(ES) ( ( 0104 PRESSUREDOUBLE-WALLED P1PE 02 05 SUCTION CONCRETE-LINED(( ) 06UNKNOWNTR(N 1H 07( ) 03 3 GRAVITY <br /> NONE <br /> B UNDERGROUND <br /> APPROPRIATE BOX(ES) ( ( 01 40PRESSURELEDXP105 SUCTION CONCRETE-LINED) 06UNKNOWNTREN CH 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> 05 <br /> ;l f ) VISUAL <br /> GROUND(WATER MONITORINGNWELLS (f1)O 07VAPOR PRESSUREFTESTLLSX)( INSTRUMENT <br /> ) 02 STOCK 09 NONE <br /> 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECK EC YES TO !V-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# ('+F KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) O1 ( ) 02 " f 1 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( I O1 ( 1 02 f 1 03 <br /> [ ) 01 ( 1 02 ( 1 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> [ ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 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 COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PHONE W/AREA CODE <br /> PERSON FILING (SIGNATURE) <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY <br /> CITY CODE COUNTY COD! <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) <br /> 01 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />