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. STATE ID NUMBER 00000002918013 <br /> CONTAINER CONSTRUCTION <br /> ( 1 O1 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A (CHECKRAPPROPRIATE•BOX ES) ( ( 0)104DOUBLE-WALLED )IPE 02 05 SUCTION CONCRETE-LINED( ) 06UNKNOWNTR`N]H 3 GRAVITY <br /> 07(NONE <br /> B (UNDERGOUND CHECKRAPPROPRIATE•BOX(ES) f ( 011040 PRESSURELEO 1105 SUCTION CON;R 06E3 GRAVITY <br /> UNKNOWN <br /> 0 <br /> VII LEAK DETECTION <br /> 1 05 <br /> INSTRUMENT <br /> (X( O1 06I <br /> IGROUNDI WATER MONITORINGNWELLS (()7007 PRESSUREAPOR TEST EN <br /> VSUAL ) 02 STOCK TESTEES 1(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 PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STOPED STORED <br /> D <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( l 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> ( ) 01 ( 7 02 ( 103 <br /> ( 7 01 ( 1 02 ( 1 03 <br /> ( 7 <br /> 01 ( 1 02 ( l 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> f 1 <br /> 01 ( ) 02 ( ) 03 <br /> L ( ) 01 f 1 02 f ) 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 M HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PHONE W/AREA <br /> PER N fILIN3 (S GNATV <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY 000E <br /> ADMINISTTIN AGE NCY <br /> CONTACT PERSON„ _ al PHONE W/AREA CODE LO <br /> 2 ^ , <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 2 01 YES ( 1 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />