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rnNTATNFR CONSTRUCTION <br />y <br />STATE ID NUMBER 00000010994004 <br />01 RUBBER LINED f l 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f 7 05 NONE <br />f ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />1. ABOVEGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE-LINEO TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(E5) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />3. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH (X) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ( ) 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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( I 01 <br />( ) 02 <br />( ) 03 <br />;( ) O1 <br />( ) 02 <br />( ) 03 <br />�( ) 01 <br />( ) 02 <br />( ) 03 <br />( 1 O1 <br />( ) 02 <br />( ) 03 <br />:( 1 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( 1 02 <br />( ) 03 <br />( 1 01 <br />f 1 02 <br />( ) 03 <br />1 01 <br />f ) 02 <br />( ) 03 <br />CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />5 CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br />Titin FORM HAS BEEN COMPL <br />ER THE PE <br />Of PERJURY AND, TO THE BEST OF MY KNOWLEDGE, <br />IS TRUE AND CORRECT. <br />I:ERSON FILING (SIGNATI <br />lid:PHONE <br />33 <br />L <br />FOR LOCAL AGENCY <br />USE ONLY <br />IF'�YEN ISTRATI NG AGENCY <br />A , <br />_� ( <br />CITY ORE <br />COUNTY CODE <br />CONTACT PERSON U PHONE W/ARE CODE f'-'7 <br />) \ ) — �`l I <br />DATEV`OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO rt <br />( ) 01 YES ( 1 02 NO <br />PAGE 2 <br />`SC04-070185 (10/16/85) <br />