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• • STATE IO NUMBER 00000049917002 <br /> CONTAINER CONSTRUCTION <br /> E [ )(0) RUBBER LINED(X7 08 UNKNOWN L(N 7N09 OTHER'- ON <br /> EPDXY LINING ( ) 04 PHENOLIC LINING 05 GLASS LINING <br /> ( ] <br /> 07 <br /> NED <br /> F [ 1(01 POLYETHLENE WRAP <br /> (( ))02 VINYLWRAPPING ( ) 03 CATHODIC PROTECTION [Xl 04 UNKNOWN ( l 05 NONE <br /> VI PIPING <br /> A ABOVEGROUNDRIATE <br /> [ ( 0104 PRESSURE LED PIPE <br /> SUCTION CONCRETE-LINED 006UNKNOWNTR ENI"07(NONE3 GRAVITY <br /> 01DOUBLE-WALLEDPICONCRETE-LINED ETREN)H ( 3 GRAVITY <br /> B UNDERGROUND <br /> PIPING: <br /> 06UKOWN07NONE <br /> ( EPBOX(ES) 04 PRESSUREX05 SUCTION <br /> VII LEAK DETECTION <br /> NSTRUMENT <br /> ( ` 01VISUAL <br /> GROUN0 WATER MONITORINGNWELLS �„ 07TORY 04 VPRESSUREAPOR F TESTEES 1(09 NONE05 ENSOR 1 <br /> 060 OTHER: <br /> VIIIHEMICO Les OMPOSITIO TO IV-F YOU e OF AOT PE MATERIALS <br /> cS STORED LETE THIS SECTION IGUNDERGROUND CONTAINERS <br /> IF YCU <br /> CURRENTLY PREVIOUSLY DELETE CASK fIP KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (XI 01 ( ) 02 ( ] 03 <br /> MOTOR OIL <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 7 <br /> 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 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 (SIGN E) /) <br /> tlaz <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CCOE <br /> ADMINISTRATING 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 ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />