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�./ STATE ID NUMBER 00000066435001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1(X)01 RUBBER LINED( ) 08 UNKNOWN LINING <br /> 09 OTHER3 EPDXY LINING ( 1 04 PHENOLIC LINING f 1 OS GLASS LINING <br /> NED <br /> F. f ) O1 POLYETHLENE WRAP I 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION t ) 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT l 1 09 OTHER: <br /> VI PIPING <br /> A (CHECK APPROPRIATEDBOX(ES) I ( 0104 PRESSURELEO )IPE 02 05 SUCTION C(X) 06EUNKNOWN (TRENCH 07(NONE GRAVITY <br /> B. (CHECK APPROPRIATE BOX(ES) ( ( 0104 PRESSURE 05 <br /> PIPE <br /> 05 SUCTION CONCRETE-LINED 06 UNKNOWN NONE GRAVITY <br /> VII LEAK DETECTION <br /> ( ; ) 06IGROUND(NATER MO02 NITORINGS WELLS (f 11D07VPRESSURESNIFF <br /> TESTWELLS <br /> 1 )f 09 DNONEEN(Dl INSTRUMENT <br /> 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 /> ( ] Ol I 1 02 I 1 03 <br /> f 1 Ol f l 02 1 ) 03 <br /> ( 1 Ol f 1 02 ( ) 03 <br /> ( 1 01 [ 1 02 ( ) 03 <br /> f 1 <br /> 01 1 ) 02 ( ) 03 <br /> l 1 <br /> 01 f ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f 1 O1 ( ) 02 ( 1 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) <br /> al 1 ) 02 ( 1 03 <br /> CHEM( STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? (X) 01 YES ( ) 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 /> PERSON FILING (SIGNATURE) 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 IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 O1 YES ( ) 02 NO <br /> HSC04-070185 (08/29/861 PAGE 2 <br />