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• 0 STATE ID NUMBER 00000052077001 <br /> CONTAINER CONSTRUCTION <br /> E. t )t0) RUBBER ILINED(X1 08 UNKNOWN 02 ALKYD LIN N09 OTHERS EPDXY LINING t 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> NED <br /> F. t )(0) R6LTARNORNE WR ALT t(1 VINYL 1 ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN l ) 05 NONE <br /> PH <br /> VI PIPING <br /> 03 GRAVITY <br /> A. ABOVEGROUND PIPING l ) O1 DOUBL�PIPE f ) 02 CONCRETE-LINED TRENCH f(CHECK APPROPRIATE BOXfESI ( ) 04 PRE05 SUCTION JX) 06 UNKNOWN t ) 07 NONE <br /> B <br /> UNDERGROUND PIPING ( ) O1 DOUBLE-WALLEO PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( 1 04 PRESSURE tXl 05 SUCTION ( 1 Ob UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ,( ` Ol OVIGROUNDSUAL t WATER STOCK INVENRING TORY t(11D 07V PRESSUREAPOR SNFTESTLLSX 1t 09 NON€05 ENSOR INSTRUMENT <br /> VIII}CHEhi�AL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED 9Y ES_ ��-_.V�F YCV ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> CURRENTLY PREVIOUSLY DELETE CASB' �`.'P-KNOWN) <br /> STORED STORED - <br /> I <br /> ( ) 01 ( 1 02 ( 1 03 <br /> t ) Ol t ) 02 ( l 03 <br /> ( 1 01 ( 1 02 f 1 03 <br /> f ) Ol f ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> t ) 01 ( 1 02 f 1 03 <br /> ( ) O1 t ) 02 ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 t 1 03 <br /> ( ) 01 ( 1 02 f ) 03 <br /> ( ) <br /> 01 f 1 02 t ) 03 <br /> i, CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 YES (X) 02 ND <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE 8PHONEF WMAREAKNOWLEDGE, IS TRUE AND CORRECT. <br /> CODE <br /> PERSON FILING (SIGNATURE) <br /> FOR LOCAL AGENCY USE ONLY carr CODE COUNTY CODE <br /> ADMINISTRATING AGENCY <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> PERMIT APPROVAL DATE <br /> TRANSACTION DATE LOCAL PERMIT ID 1i <br /> DATE OF LAST INSPECTION IN COMPLIANCEOIYES ( ) 02 NO <br /> PAGE <br /> HSC04-070185 (10/18/85) <br />