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STATE ID NUMBER 000OOOD598 <br /> 6001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RER LINED 4 ) 02 ALKYD KNOWN LININ 09 OTHE03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINIt:G <br /> ( ) 0LINED (X) 08 UNF. t ) O1 PTHLENE WRAP [ ) 02 VINYL WRAPPING03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE) 0R OR ASPHALT ( ) 09 OTHER <br /> VI PIPING <br /> A. ABDV€GROUNRPIPING:OPRIATE BOX ES) ( i 0104 PE It 02 <br /> PRESSUREWA L LEOf PIPE <br /> SUCTION C[(DNCR06EUNKNOWNTR(N)H07(NONE3 GRAVITY <br /> (CHECK APP <br /> B. UNDERGROUND PIPING ( } O1 DOUBLE—WALLED PIPE l ) 02 CONCRETE—LINED TRENCH t } 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( } 04 PRESSURE (X) 05 SUCTION i } 06 UNKNOWN [ } 07 NONE <br /> VII LEAK DETECTION <br /> ( 0) D1VSUAL05IGSU4ROUND(WATER MONITORINGINVENTORY <br /> WELLS ((X)007VPRESSUREFTESTLLS )i 09 NONE 05 ENfOR INSTRUMENT OT <br /> HER: <br /> T — <br /> MATERIALS P STORED SEN ION IN CONTAINERS <br /> VIII CHEMICAL COMPOSITION OF <br /> ' <br /> 70 <br /> IF 'ICU CHEOF:ED 'i ES TO 1,,,-F YOU ARE NOT PE4JIREa <br /> CUPPENTLY PREVO'JSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t ) 01 ( ) 02 f ) 03 <br /> ( ) 01 ( ) 02 [ } 03 <br /> ( D <br /> 01 [ } 02 It D 03 <br /> l ) 01 f } 02 i D 03 <br /> ( } 01 ( D 02 [ } 03 <br /> ( ) Q1 ( ) 02 t 1 03 <br /> ( ) 01 ( ) 02 i ) 03 <br /> ( ) 01 It ) 02 ( ) 03 <br /> ( ) 01 ( } 02 [ ) 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 KNOWLEDGEs IS TRUE AND CORRECT. <br /> PHONE W/APER CODE <br /> PERSON FILING (SIGNATURE) EA � �b z P z� <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY GODS COUNTY CODE <br /> ADMINISTRATING AGENCY' <br /> S' stir' tri f-� r n1 Le��2 1 ri f/ <br /> PHONE W/AREA CODE <br /> CONTACT PERSON iy� �Vq ri z Z'/ <br /> . <br /> r TRANSACTION DATE LOGAI PERMIT IO # <br /> 04TE OF LAST INSPECTICN IN COMPLIANCE PERMIT APPROVAL DATE <br /> ( ) 01 YES ( ) 02 N0 <br /> PAGE 2 <br /> HSC04-0701$5 <br />