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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E ( )[ORUBBER LINEDLINING 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LI <br /> l 07 UNLINED (X] OS UNKNOWN ) 09 OTHER: <br /> F. ( ) O1 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION l 7 04 UNKNOWN (X) 05 NONE <br /> f ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( 7 02 CONCRETE-LINED TRENCH [ 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> INED <br /> B (1CHECKRAPPR APPROPRIATE: <br /> BOX(ES) ( (X1104 PRESSURELED P105 SUCTION CON;R 006EUNKNOWNTR(N CH 07( 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> ( ) O1 VISUAL (XI 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTH ER � (r CJO� <br /> VIII Y CHEMICAL <br /> L Es COMPOSITIOTO IV-F YOU N <br /> OFOT R MATERIALS ETTORED SECTION NDERGROUND CONTAINERS <br /> IFYOU <br /> (00 NOT USE COMMERCIAL NAME) <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> STORED STOPED <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( 7 01 ( 1 02 ( ) 03 <br /> ( ) 01 [ 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( 7 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ] O1 ( l 02 ( ) 03 <br /> ( ) <br /> 01 l ) 02 ( ) 03 <br /> ( ) O1 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 YES (X) 02 NO <br /> THIS FORM N COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PHONE W/AREA OODE <br /> PERSO FIL ON ) 7C <br /> FOR LOCAL AGENCY ; E ONLY <br /> CITY CODE _ COUNTY CODE <br /> ADMINISTRATING GENCY �G" <br /> PHON W/A EA CODE <br /> CONTACT PERSON I <br /> / <br /> 1 <br /> IPERMIT APPROVAL GATE TRANSACTION DATE LOCAL PERMIT ID # <br /> DATE OF LAST INSPECTION N COMPLIANCE <br /> ( ) <br /> 01 YES ( 1 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />