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STATE ID NUMBER 00000002794004 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( 1 02 ALKYO LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 O1 POLYETHLENE WRAP ( ] 02 VINYL WRAPPING ( 7 03 CATHODIC PROTECTION [ l 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING 02 <br /> A (CHECKRAPPR OPIPING:BOX(ES) f ( 010DOPE4 UBLE-WALLED 1105 SUCTION CON;R CONCRETE-LINED TRENCH <br /> 07f NONE3 GRAVITY <br /> B (CHECKRAPPROPRIATE: <br /> PPR PRIATE•BOX(ES) ( ( 0104 PRESSURELED(XP105 SUCTION CON;R 06EUNKNOWNTREN'H 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> INSTRUMENT <br /> ( ( 01VSUAL 061 GROUND( ) 02 STOCK WATER MONITORINGNTOYWELLS ((1)007VAPOR <br /> PRESSURESNIFF <br /> TESTWELLS <br /> X)( 05 09 NONESENSOR 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-P YOU .ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> C <br /> URRENTLY PREVIOUSLY DELETE CASC (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED <br /> ( ) 02 ( ) 03 <br /> ( ) 02 f ) 03 <br /> f ) 02 ( ) 03( ) 02 ( ) 03( ) 02 ( ) 03( ] 02 l 1 031 ( 1 02 ( 1 031 ( 7 02 f 1 031 ( ) 02 ( 1 03 <br /> ( 1 <br /> 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 <br /> PERSON FILING (SIGNATURE) <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> ACMINISTPATING 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 /> ( ) <br /> 01 YES ( 1 02 NO - <br /> PAGE 2 <br /> HSC04-070185 (30/18/85) <br />