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STATE ID NUMBER 00000001833001 <br /> CONTAINER CONSTRUCTION <br /> E <br /> O1 RUBBER LINED t ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ) 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER) 7dO1 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f 7 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ) 06 TAR OR ASPHALT l 7 09 OTHER: <br /> VI PIPING <br /> A AlBOVEGROUND <br /> APPROPRIATE BOXES) (( 0104 PRESSURELED P1PE 02 05 SUCTION CONCRETE-LINED( ) 6UNKNOWN (TRENCH 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> B UNDERGROUND <br /> BOX(ES) ( ( 0104 PRESSURELE(X) 05 SUCTION CON;R 06EUNKNOWN (N)H07( 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS ( ) 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 ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) O1 ( 1 02 ( 1 03 <br /> [ 101 ( ) 02 ( ) 03 <br /> ( ] <br /> 01 f 7 02 ( ) 03 <br /> f ) al ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( I <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( l 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> x 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 P PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> FE P.SONF LIND (SIONA :ZRE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF. LAST INSPECTION INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />