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r 0 STATE ID NUMBER 00000044927001 <br /> CONSTRUCTION ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> CONTAINER ( ) 03 'FOX <br /> E' 0l RUB <br /> Y LINING <br /> ( ) 02 ALKYD LIN�W U9 OTHER lXl 04 UNKNOWN l 1 05 NONE <br /> ( )( UNLINEDEOIX) OB UNKNOWN ( <br /> e RAP1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION <br /> F' ( 1(0pOYET <br /> ) p6LTARH ORt1 ASPHALT (( ) 09 OTHER <br /> ( ) 03 GRAVITY <br /> ( 1 02 CONCRETE-LINED TRENCH <br /> 07 NONE <br /> V I <br /> PIPING ( ) 06 UNKNOWN <br /> ( ) Ol DOUBLESWALLED PIPE SUCTION ( ) 03 GRAVITY <br /> A. ABOVEGROUND PIPING ( ) Oq PRESSURE <br /> (CHECK APPROPRIATE BOX(ES) <br /> 1 02 CON;R 06EUNKNOWN NED THE 1H 07 NONE <br /> ( ( 0104 PRESSURELE(X) 05 SUCTION <br /> B. UNDERGROUND PIPING <br /> (CHECK APPROPRIATE BOX(E57 <br /> V I I L E A K DETECTION ( ) 05 SENSOR 114STRUMENT <br /> ( ) 04 VAPOR SNIFF WELLSX) 09 NONE <br /> ( 1 a OTHERZ <br /> O1 VISUAL ( 1 02 STOCK INVENTORY ( ) 07 PRESSURE TE57 CONTAINERS <br /> ( ) 06 GROUND WATER MONITORING WELLS STORED IN UNDERGROUND <br /> VIII CHEMICAL COMPOSITION OF MATERIALS <br /> YES TO IV.F YOU ARE NOT RECUIRED TO COMPLETE THIS SECTION USE COMMERCIAL NAME) <br /> IF YOU CHECKEC <br /> CHEMICAL (00 NOT <br /> CUR RlNT LY PREVIOUSLY DELETE CASA (IF KNOWNI <br /> STORED STORED <br /> l ) 01 t 1 02 ( ) 03 <br /> ( ) O1 ( ) 02 l 1 03 <br /> LD <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( 1 O1 ( ) 02 t 3 <br /> ] 0 <br /> ( 1 ( ) 02 ( ] 03 <br /> Ll I <br /> 01 <br /> l 1 01 ( 1 02 ( 1 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ] 03 <br /> ( ) 01 E ) 02 ( ) 03 <br /> � CHEMICAL CODE LISTING FOR P05SIBLE SYNONYMS <br /> CHECK STATE BOARD <br /> (X) 02 NO <br /> IS CONTAINER <br /> LOCATED ON AN AGRICULTURAL FARM? t ) O1 YES AND CORRECT. <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PEp <br /> NALTY OF PERJURY AND, TO THE BEST OF MY KNOWLE <br /> PHONE W/AREA CODEDGE, IS TRUE <br /> pEpSON FILING (SIGNATURE) <br /> COUNTY CODE <br /> FOR LOCAL AGENCY USE ONLY CITY CODE <br /> AOMINISTRATINO AGENCY pHONE W/AREA CODE <br /> CONTACT PERSON LOCAL PERMIT IO <br /> PERMIT APPROVAL DATE <br /> TRANSACTION GATE <br /> DATE OF LAST INSPECTION ZN COMPLIANCE <br /> ( ) <br /> 01 YES ( ) 02 N0 P <br /> HSC04-070185 110/18/85) <br /> • <br />