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STATE ID NUMBER 00000012411002 <br /> CONTAINER CONSTRUCTION <br /> PCX)01 RUBBERZLINED <br /> I 1 08 UNKNOWN L(N 1N09 OTHERS EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> NED <br /> O1 POLYETHLENE WRAP ( ] 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X1 04 UNKNOWN [ 1 05 NONE <br /> 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING 02 <br /> A (CHEOKRAPPROPIPING:BOX(ES1 ( ( 01104 PBLE-WALLED PI05 SUCTION CON) 06EUNKNOWNTRENCH 07f NONE3 GRAVITY <br /> f 1DOUBLE-WALLED <br /> LEDP1CONCRETE-LINED <br /> TRENCH ( 3 GRAVITY <br /> BPNDRGROUNDIPIG: 07NONE <br /> EAPPROPRIATE (X) 04PRESSURE05 SUCTION <br /> VII LEAK DETECTION <br /> m) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 7 07 PRESSURE TEST ( 1 09 NONE C 1 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 /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> CURRENTLY PREVICVSLY DELETE CAS# (IF KNOWN) <br /> STORED STORED <br /> f ) <br /> 01 ( ) 02 ( 1 03 <br /> l 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( 9 Ol [ 1 02 f 1 03 <br /> ( 1 01 ( ) 02 f 1 03 <br /> ( ] Ol f 1 02 ( ) 03 <br /> ( 101 ( 1 02 ( ) 03 <br /> ( ) 01 f ) 0 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 f ) 03 <br /> l 1 Ol ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) Ol 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 /> 1 PHONE W/AREA CODE} <br /> PERSO FILING (SIGNATURE) <br /> Vq <br /> ry I <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> ADMINISTRATING AGENCY <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> TRANSACTION DATE LOCAL PERMIT ID # <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE <br /> - <br /> ( ) O1 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />