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r <br /> STATE ID NUMBER 00000038814003 <br /> CONTAINER CONSTRUCTION <br /> Ell)jt0lRUBBER LINED ( ) 02 ALKYD LINING03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING07 UNLINED (X) 08 UNKNOWN09 -0THERPOLYEIHLENE WRAP ( ) 02 VINYL WRAPPING03 CATHODIC PROTECTION (X1 04 UNKNOWN ( 1 05 NONE <br /> 06 TAR OR ASPHALT ( ] 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) (&S 04 PRESSURE ( ) 05 SUCTION (M 06 UNKNOWN ( ) 07 NONE <br /> B (1CHECKRAPPROPRIATEPIPING! <br /> BOX(ES) ( 1104 PRESSURE 05 DOUBLE-WALLED <br /> PIPE <br /> 05 SUCTION CONCRETE-LINED <br /> UNKNOWNTRENCH <br /> 07(NONE3 GRAVITY <br /> VII LEAK DETECTION <br /> TRUMENT <br /> (X( ) VISUAL <br /> X) Oa STOCK WATER MONITORINGNWELLS (()1007VAPOR <br /> PRESSURESNIFF <br /> TESTWELLS 1(09 NONE05 ENSOR 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 /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> CURRENTLY PREVIOUSLY DELETE GAS# (IF KNOWN) D <br /> STORED STORED <br /> ( ) 01 ( 1 02 f l 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 7 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( 1 02 t 1 03 <br /> ( 1 O1 ( ) 02 t ) 03 <br /> ( ) 01 ( l 02 f 1 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> ( 1 01 ( ) 02 f 1 03 <br /> ( ) 01 ( l 02 ( 1 03 <br /> ( ) Ol f 1 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> -2- <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATING AGENCY 9 f CITY CODE COUNTY CODE <br /> �S4 / U l%l Loc 4rc- 1-)-e A L <br /> PHONE W/AREA CODE <br /> CONTACT PEPSON <br /> DATE IOFLN$F CTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID it <br /> Ol YES f 1 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />