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STATE ID NUMBER 00000010781007 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( } 05 GLASS LINING <br /> (X) 07 UNLINED ( } 08 UNKNOWN ( ) 09 OTHER <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> [ 1 06 TAR OR ASPHALT ( 1 09 OTHER' <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE t } 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( l 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE f l 02 CONCRETE—LINED TRENCH ( r 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE [ l 05 SUCTION ( ] 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> Fo1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( l 04 NONE (Xl 10 OTHER LINE LEAK DETECTQR <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKE0 YES TO IV-F ACU .ARE NOT RER'JIRED TO COMPLETE THIS SECTION <br /> CU=RENTLY PREVIOUSLY DELETE CAS# tIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( r 01 ( ) 02 ( ] 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> E } <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 i ) 02 ( ) 03 <br /> t ) 01 ( ] 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 11 1 J I I 1 1 <br /> ( ) 01 t } 02 ( ] 03 <br /> ( 1 01 ( ) 02 ( l 03 <br /> t r 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( 1 02 t ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> �ISCON�TAINER�LOCATEDN AGRICULTURAL FARM? ( lO1 YE5 (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 FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSRECTICN IN COMPLIANCE <br /> ]PERMIT <br /> APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID x <br /> ( ) O1 'YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />