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STATE ID NUMBER 00000018913002 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING f ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: <br /> F. [ ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION f 1 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A ABOVEGROUND <br /> BOX(ES) ( ( 0104 PRESSURELED )IPE 02 05 SUCTION CONCRETE-LINED( ) 06UNKNOWNTR(N) 07 3 GRAVITY <br /> (NONE <br /> B UNDERGROUND <br /> BOX(ES) [ (X11 4O PRESSURELED PI <br /> I05 SUCTION CONCRETE-LINED 6UNKNOWNTR(N)H 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( ] 05 SENSOR INSTRUMENT yy�� <br /> ( 1 06 GROUND WATER MONITORING WELLS f O 07 PRESSURE TEST ( ) 09 NONE 10 OTHER: LJ` , L,eak OC+'eC+Or <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 /> CURRENTLY PREVIOUSLY DELETE CASX (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( I al [ ) 02 ( 1 03 <br /> ( ) 01. ( 1 02 [ 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 [ 7 02 ( 103 <br /> ( ) O1 ( l 02 [ 1 03 <br /> ( ) 01 l 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( ) <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 /> PERSO FILING / IGN VRE PHONE W/AREA CODE <br /> Z. o <br /> FOR LOCAL AGENCY USE ONLY <br /> AOM�z STRATING AGENCY CITY CODE COUNTY CODE <br /> �av�-yoa a <br /> CONTACT PERSON PHONE W/A�R'EA;CODE <br /> DATE OF L T Z�S CTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO a <br /> -3-13 /Y,_ ( 1 01 YES02 <br /> )�02 NO <br /> HSC04-070185 (10/18/85) / /4 ,/ f,y1 . PAGE 2 <br />