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STATE 10 NUMBER 00000049917003 <br /> CONTAINER CONSTRUCTION <br /> ( )( RUBBER LINED <br /> ED (X) 08 UNKNOWN L( <br /> 1 UN)N 09 OTHER:03 EPDXY LINING ( 104 PHENOLIC LINING ( ) 05 GLASS LINING <br /> E O <br /> F, ( ] 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A (CHECK APPROPRIATE: <br /> BOX(ES) ( ( 0104 RESSURELED P1CONCRETE-LINED <br /> 05 SUCTION ( 0 3 GRAVITY <br /> UNKNOWN <br /> 07(NONE <br /> X) 03 <br /> B (CHECKR APPROPRIATE BOX(ES) ( ( 0104 PRESSURELED P105 SUCTION CON;R 006EUNKNOWNTR(N;H 07(3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> ( ( 1GROUND WATER MONITORING TORY04 <br /> 007VPRESSURE APOR F <br /> TESTLL.J P 09 NONES 05 EN( ) <br /> R INSTRUMENT <br /> 1 06 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 /> [CUPPENTLY PREVIOUSLY DELETEjCAS## KNOWN) <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> ED STORED <br /> O1 ( ) 02 ( ) 03 <br /> O1 ( ) 02 03 <br /> 01 ( ) 02 ( 7 03 <br /> ( 1 Ol ( ) 02 ( 1 03 <br /> ( ) Ol ( 7 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 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 fSZGNATUREI <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <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 /> ( ) O1 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />