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• iSTATE ID NUMBER 00000018854002 <br /> CONTAINER CONSTRUCTION <br /> Ell)(,111RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING l ) 05 GLASS LINING <br /> 07 UNLINED ( ) O8 UNKNOWN ( 1 09 OTHER: <br /> POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION04 UNKNOWN (X) 05 NONE <br /> 06 TAR OR ASPHALT [ ) 09 OTHER: <br /> VI PIPING <br /> A ABOVEGROUND <br /> PRIATE•BOX(ES) ( ( 011 04 PRESSURE <br /> ) 005 02 SUCTION CONCRETE-LINED( ) 06UNKNOWNTR(N)H3 GRAVITY <br /> 07(NONE <br /> B UNDERGROUND <br /> BOX(ES) ( ( 0104 PRESSURE <br /> PIPE 05 SUCTION CON)R06EUNKNOWNTR(N)H 07(NONE GRAVITY <br /> VII LEAK DETECTION <br /> INTUMENT <br /> ( ` ) 061SUAL GROUNDIX) 02 STOCK WATER MONITORINGNTOYWELLS 04 <br /> 007 PRESSUREAPOR FTESTLLS )(09 NONE05 EN( ) 10SOTHER: <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 STOPED <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( } 0.1 l ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( } 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 l ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ■ 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 OF P JURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE p� <br /> FOR LOCAL AGENCY USE ONLY <br /> O�'ST CITY CODE COUNTY CODE <br /> ADMINISTRATING AGENCY 4� �J <br /> /V 1 <br /> CONTACT PERS ��/Y�G PHONE W/ $,IDE ^/ `/ (^ <br /> DATE OF LAST }(��PICTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE _ILOOCAL PERMIT ID # <br /> Ol YES f ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br /> • <br />