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STATE ID NUMBER 00000010908001 <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( ) 02 ALKYO LINING t l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 105 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A I50VEGROUND PIPING:RIATE BOX(ES) ( ( 0104 PRESSURELE ID PIPE <br /> 05 SUCTION CONCRETE-LI06 NED TRENIH07(N) 03 GRAVITY <br /> CHECK <br /> APPR <br /> B (CHECKRAPPROPRIATE•BOX(ES) ( ( ) 04OPRESSURELE& 05 SUCTION COREY 06EUNKNOWNNCRET -LINEDTRENOH 07(NONE3 GRAVITY <br /> VII LEAK DETECTION <br /> ( ) O1 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST (X) 09 NONE ( ) 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 CAS4 (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> f ) -fll ( ) 02 ( ) 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 f ) 02 ( ) 03 <br /> l 1 01 ( ) 02 ( ) 03 <br /> f 1 Ol ( ] 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 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 PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FS (SIGN 1 ONE REA COD <br /> X o <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AS OY CITY CODE COUNTY CODE <br /> lD L i5 <br /> CONTA PERSON PH NE W/ REA CODE <br /> 'ONTANWN <br /> DATE OF AST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DAT(✓�'ELOCAL PERMIT ID A <br /> ( 1 Ol YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />