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• <br /> STATE ID NUMBER 00000002918009 <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f 1 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND <br /> APPROPRIATE•BOX(ES) ( ( 1104 PRESSURELED 11PE 02 05 SUCTION CON) 06EUNKNOWNTR(N)H 07f ) 03 3 GRAVITY <br /> NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (XI 05 SUCTION f 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> INST <br /> UMENT <br /> (X(1 0106VISUAL <br /> GROUNO(WATER MONITORING INVENTORY <br /> WELLS (f ))007VAPOR <br /> PRESSURESNIFF <br /> TESTWELLS 1(09 NONE <br /> 05 SENSOR <br /> 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 /> CVRRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( l 01 ( 1 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( l 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> f ) 01 f 1 02 ( ] 03 <br /> ( 1 01 f ] 02 f 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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 /> RERS FILING (SIGN TUR 1, PHONE W/ARE A_CO' �—7� <br /> Rs F" /j <br /> FOR OCAL AGENCY USE ONLY <br /> ADMIN25 RATING ACE NCY Q (S`T CITY CODE COUNTY CODE <br /> -Al" Jo w n/ Lo L- tNO <br /> —zCONTACT„PERSON PRONE W/A0A CODE V� 7DATE OF LAST INSPECTION IN COMPLIANCERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES ( ) 02 <br /> O PAGE 2 <br /> HSC04-070185 (10/18/85) <br />