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%W � ( STATE ID NUMBER 0000003557700 <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING 1 1 05 GLASS LINING <br /> l 1 07 UNLINED (X) 08 UNKNOWN l 1 09 OTHER: <br /> F. 1 1 01 POLYETHLENE WRAP l 1 02 VINYL WRAPPING f 103 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH l 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE l 1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GRO ATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE l 1 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 /> CURRENTLY PREVICUSLY DELETE CAS# IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> 1 1 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> 1 1 Ol l 1 02 1 1 03 <br /> l 1 01 ( 1 02 ( 1 03 <br /> 1 ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> f l Ol f l 02 1 1 03 <br /> R CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY F ERJU NO, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> FE:SON FIIINO (SIGN URE PHONE W/ARG CODE <br /> -76 $ o <br /> FOR LOCAL AGENCY USE ONLY <br /> ADM:NISTA A.jj9& IL-^ u � _ I �d U� J 57 CITY CODE COUNTY COD! <br /> CONTACT PERSON L•L+ 0��� I` 11 PHONE W/AREA CODE <br /> DATE Of LASTN P CTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION OAT! LOCAL PERMIT :0 # <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 110/18/851 PAGE 2 <br />