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STATE ID NUMBER 00000039008001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( 7 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ] 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A (CHECKRAPPROPRIATE. <br /> PPR PRIATE•BOX(ES) ( ( 0104 PRESSURELED P1PE 02 05 SUCTION CONCRETE-LINED( 06" NOWNTREH 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE [ 1 05 SUCTION (X) 06 UNKNOWN 4) 07 NONE <br /> VII LEAK DETECTION <br /> ,JX) 01061SUAL GROUND( ) 02 STOCK WATER MONITORINGNTORYWELLS (())007 PRESSUREAPOR TESTEES )(09 NONE05 ENSOR 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 (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 7 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ] 02 _- ( ) 03 <br /> ( ) Ol f 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 t 1 03 <br /> ( ) <br /> 01 f ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( l 01 ( 1 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X1 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 ATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE LY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANC! PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PlRMIT SD 1t <br /> ( ) 01 YES f ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />