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STATE IO NUMBER 00000002918007 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING f l 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION l ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> VI PIPING <br /> EABOVEGROUNDPROPRIATE•BOX(ES1 ( ( 01104 PRESSURELED PIPE 02 05 SUCTION CON;R06EUNKNOWNTR(N;H O7I NONE3fiRAVITY <br /> ND PIPING: ( ) Ol DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> PROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> INSTRUMENT <br /> (X( ) 06ISUAL GROUND(X) 02 STOCK WATER MONITORINGNWELLS (( l)007VAPOR <br /> PRESSURESNIFF <br /> TESTWELLS )f 09 NONE05 ENSOR 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 /> moz <br /> LY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED <br /> ( l 02 ( ) 03 1 ( ) 02 ( ) 03l f 1 02 ( ) 03l ( 1 02 ( ) 031 ! ) 02 ( ) 031 ( ) 02 ( ) 031 ( ) 02 ( ) 03l ( ) 02 ( ) 031 ( ) 02 ( ) 031 t ) 02 ( ) 03 1 1 1 1 1 1 1 1 1 1 1 9 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> I3 CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> TH S ORM HAS BEEN COMPLETED LjkDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PE. 0 FIL (S N. UPE) PHONE W/AREA coo;,,,, <br /> OOE �_ 7Y11 <br /> FO LOCAL AGENCY USE ONLY /`'P/f <br /> �S CITY CODE COUNTY CODE <br /> ADMINIST,R ATING AGENCY /'A J L> <br /> PHONE W/A <br /> CONTACT PERSON ( ESACODE <br /> , <br /> (� <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 2D # <br /> $' ( ) 01 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />