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0 0 <br /> CONTAINER CONSTRUCTION STATE ID NUMBER 0000'0045121003 <br /> F <br /> ) of RUBBER LINED ( ) 02 ALKYD LINING ( J 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> r 01 POLYETHLENE WRAP t 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER= <br /> VI PIPING OlDLE�� <br /> ICONCRETE-LINED <br /> flRETRENCH 03 GRAVITY <br /> A <br /> . ABOVEGROUND 07NnN <br /> PQ04PRESSUREU05 SUCTION X) 06UNKJAPRB. UNDERGROUND PIPING: t 1) 04LE( 11CON1R06ETRENjH ( E3GRAVITY <br /> PE 02 <br /> APPROFRIATE BOXES) PRESSURE (X) SUCTION UNKNOWN07 NONE <br /> VII LEAK DETECTION <br /> (XI 01 VISUAL (X) 02 STOCK INVENTORY i ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> € ) 06 GROUND WATER MONITORING WELLS E ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION TION OP HATCOMPLETE SORED AN UNDERGROUND CONTAINERS <br /> IF You ES APE NOT RRED Ta SIO <br /> FCJPPENTLY PREVIOUSLY DELETE GAS# LIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED( r 02 t ) 03 <br /> ( ) Al t ) 02 ( ) 03 <br /> ( J 01 ( ) 02 ( ) 03 <br /> 01 02 ) 03 <br /> 01 02 f ) 03 <br /> O1 J 0 ( r 03 <br /> O1 02 ( 03 <br /> 02 t ) 03 <br /> 01 02 ) 03 <br /> O1 <br /> 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> Els <br /> ONTAINER LOCATED ON�AMAGGR�ICULTU�RALRM? ( ) of 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/q�/AREA CODE <br /> PERSON FILING (SIGNATURE)i)4 U <br /> tJ 4 U <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> ADMINISTRATING AGENC' <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE <br /> PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> t ) of YES ( 3 02 NO <br /> PAGE 2 <br /> HSC04-070185 [10/18/85) <br />