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�- gT E ID }(UMBER 00000038374001 <br /> CONTAINER CONSTRUCTION 7TT' <br /> E. ( l(xl RUBBER ILINED( 1 08 UNKNOWN LIN11409 OTHERS EPDXY LINING ( ) 04 PHENOLIC LINING f ) OS GLASS LINING <br /> 07 <br /> NED <br /> F. ( l(O1 06LTARHORNASPHALWR PT E WRAP ((11 2 VINYLWRAPPING [ ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> LA(B(11V <br /> I PIPING <br /> EGROUNDE <br /> ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH [ ) 03 GRAVITY <br /> HECK APPROXES) [ ) 04 PRESSURE ( ) 05 SUCTION [ ) Ofi UNKNOWN [ ) 07 NONE <br /> ERGROUND ( ) O1 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITYHECK APPRO%[ES) f 1 04 PRESSURE (X) 05 SUCTION [ 1 Ob UNKNOWN l ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ` DV SNIFF LLS SENSOR <br /> 10 ER <br /> VISUAL ESSURETESTl09 NO <br /> 06 GROUND ELLS 107PR <br /> VI =r YOU CHECKED CHEMICAL <br /> oo pOSITIO IV-F YOU a OF OT RMAT Eo To L!MPSETE THIS <br /> IN ION UNDERGROUND CONTAINERS <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> CUPPENTLY PPEvIOUSLY DELETE CAS# LIF KNOWN) <br /> STOPEO STORED <br /> ( ) <br /> 01 [ ) 02 ( ) 03 <br /> ( l 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( l 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 01 f 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 /> _ - PHO E W/AR A CODE <br /> PERSON FILING (SIGNATIIEE� (,nVi <br /> b - O <br /> FOR LOCAL USE ONLY <br /> CITY CODE COUNTY CODE <br /> ADMINISTRATING AGENCY (C.. 3 <br /> 5a� 1 PHONE W/A EA CODE <br /> CONTACT PERSON y� V <br /> TI ✓1 LOCAL PERMIT ID # <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION GATE <br /> ( ) 01 YES [ ) 02 NO <br /> PAGE <br /> HSC04-070185 (10/18/851 <br />