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STATE ID NUMBER 00000037266001 <br /> CONTAINER CONSTRUCTION <br /> ( 1 ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 OS GLASS LINING <br /> E. 01 RUBBER LINED ( ) 02 ALKYD LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. (CHECKRAPPROPRIATEPIPING: <br /> BOX(ES) ( ( 01104 PRESSUREDOUBLE-WALLED PIPE <br /> 05 SUCTION CONCRETE-LINED <br /> UNKNOWNTRENCH <br /> 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> B (CHECKRAPPROPRIATE'BOX(ES) ( ( 011040PRESSURELEO )I05 SUCTION CONCRETE-LINED <br /> UNKNOWNTRENCH <br /> 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> ( ( <br /> 01 (X) 02 STOCK <br /> INVENTORY <br /> (( ))007VAPOR <br /> PRESSURESNIFF <br /> INSTRUMENT <br /> VSUAL TEST WELLS <br /> )(09 NONE 05 SENSOR <br /> 10 OTHER- <br /> VIII 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 /> E <br /> LV FREVIOVSLY DELETE CAS# l2F KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED1 ( 1 02 ( ) 03l ( ) 02 t ) 03l f ) 02 ( l 03l f 1 02 ( 1 031 ( 1 02 ( l 031 ( ] 02 ( ] 03l ( ) 02 f ] 03l ( l 02 ( ] 031 ( 1 02 ( 1 03LL1 ( 1 02 ( 1 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 FO M HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> RSO LI G (SI ATURE) ONE A A CODE <br /> FO LOC L AGENCY USE ONLY <br /> CITY C E COUNTY CODE <br /> AD NISTP.ATI NG AGENCY 3 <br /> PHONI W/ARE Cq <br /> DE <br /> C NT ACT PERSON Fl A _ae <br /> DATE Of LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) O1 VES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (1.0/18/85) <br />