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0 <br /> STATE ID NUMBER 00900053870992 <br /> CONTAINER CONSTRUCTION <br /> E. l ) 01 RUBBER LINED ( ) 02 ALKYD LINING [ ) 03 EPDXY LINING ( 1 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 ( ) C4 UNKNOWN ( 1 05 NONE <br /> (X) 06 TAR OR ASPHALT t ) 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(E5) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: { 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN t ) 07 NONE <br /> VII LEAK DETECTION <br /> [ l 01 VISUAL (X1 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GF.OUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> _F YOU C°IECYSD YES TO _V-F YOU APE NOT ReTUIP.ED TO COMPLETE THIS SECTION <br /> F'T <br /> ED STOPE^v <br /> [ ) 01 ( ) 02 ( 1 03 <br /> ( ) of [ ) 02 ( ) o3 I L{ I I I I I <br /> F ) 01 ( ) 02� ( l 03 <br /> { 1 01 ( 1 02 ( l 03 <br /> ( ) 01 ( } 02 ( 1 93 <br /> E ) 01 ( ) 02 [ ) 03 <br /> { ) 01 ( ) 02 ( ) 03 <br /> { ) 01 [ ) 02 [ 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( l 01 [ 1 02 ( ] 03 <br /> ?� CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FISONTAINER LOCATED ON AN AGRICULTURAL FARM? f } 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 /> PEJFILiti� ry�ldTUPy PHONE W/.AREA CODE <br /> L L <br /> FOR LOCAL AGENCY USE ONLY <br /> AD,MINISA"it4G AGENCY CITY JO E COUNTY CODE <br /> CONT CT PERSON PHONE W/AR A CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO '.i <br /> O1 YES ( 3 C2 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />