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• 0 STATE IO NUMBER 00000056420004 <br /> CONTAINER CONSTRUCTION <br /> ( )( RUBBERILLINED <br /> (X) 08 UNKNOWN L( <br /> ) N)N 09 OTHER.03 EPDXY LINING ( 1 04 PHENOLIC LINING l 1 OS GLASS LINING <br /> E 0 <br /> F. ( 1 O1 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION (X] 04 UNKNOWN f 1 OS NONE <br /> ( ) 06 TAR OR ASPHALT f l 09 OTHER: <br /> VI PIPING 02 <br /> A (ABOVEGOUND CHECKRAPPROPIPITE•BOX(ES7 ( ( 0l DOUBLSSURELEU PIPE <br /> SUCTION CON)R06EUNKNOWNTRENCH <br /> 07(NONE <br /> GRAVITY <br /> B ()CHECKRAPPROPRIATE•BOX(ES) ( ( 01040PRESSUREDOUBLE-WALLED <br /> (X) 05 SUCTION CON IR 06EUNKNOWNTRENCH 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> 05 <br /> ( ( 01 06I <br /> 1GROUNVSUALD WA ) 02 STOCK TER MONITORINGNTORYWELLS ((1)D 07VAPOR PRESSUREFTESTLLSXI(09 NONEENI ) NST10 OTUMENT <br /> HER: <br /> VIII <br /> YOU CHEMICAL <br /> COMPOSITION TO IV-F YOU OFOT BA=RED To COMPLETE ORED SECTION IGUNDERGROUND CONTAINERS <br /> CURRENTLY PREVIOUSLY DELETE CASC (IF KNOWN) <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 7 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 f 7 02 ( ) 03 <br /> l 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( 1 03 ( ] 02 ( 7 003 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THI5 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 (SIGNATURE) <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 /> ( 7 O1 YES ( 1 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />