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STATE ID NUNSER 00000035311001 <br /> CONTAINER CONSTRUCTION <br /> E. ( } 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( } 04 PHENOLIC LINING i ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN C ) 09 OTHER: <br /> F. C ) O1 POLYETHLENE WRAP i } 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT [ ) 04 0THER' <br /> VI PIPING <br /> A. ACHECKRAPPROPPIPING: <br /> RIATE BOX(ES) ( It 01940 PRESSURE 05 <br /> PIPE <br /> SUCTION 02 C�N1R06EUNKNOWN <br /> TREN�H07(NONE3 GRAVITY - <br /> B (UNDERGCUND CHECKRAPPROPRIATE+BOX(ES) ( It01104OFRESSURELE(EXP) 05 SUCTION CONI 06E-LINEDUNKNOWNTR(N1H07( 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION -� <br /> F( ) D1 VISUAL [X1 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS { } 05 SENSOR INSTRUMENT <br /> ) 06 GROUND WATER MONITORING WELLS W4 07 PRESSURE TEST ( } 09 NONE ( } 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASA (IF KNOWN) <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( } 01 ( ) 02 C ) 03 <br /> t l 01 It ) 02 ( ) 03 <br /> i ) 01 C ) 02 ( ) 03 <br /> ( ) 01 It ) 02 C ) 03 <br /> C } 01 C 1 92 4 ) 03 <br /> f ) <br /> 01 It ) 02 ( ) 03 <br /> f l DI ( } 02 ( ) 03 <br /> C ) 01 ( ) 02 ( ) 13 <br /> } ( } 01 It l 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> 71 <br /> FISCONTAINER LOCATED ON AN AGRICULTURAL FARM' f ) 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/AREAS"COD <br /> P'P50 <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CCDE 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 4 <br /> ( ) 01 YES ( ) 02 NO <br /> PAGE. 2 <br /> HS1:04-070185 (10/18/85) <br /> i �' <br />