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STATE IO NUMBER OOOOQ042548002 <br /> CONTAINER CONSTRUCTION _ <br /> E. f } 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING f i 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER- <br /> F. ( ) OI POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( } 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: -� <br /> VI PIPING <br /> EAEGR BOVDUNOPIPIPRIATE BOX(ES) ( ( (}104OPRESSURELED PIPE <br /> Sl7CTI0N 02 CONCRETE-LINED) Q6UNKNOYJNTR[}�1H07(NONE3 GRAVITY <br /> PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH [ 1 03 GRAVITY <br /> OPRIATE BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ( l 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ` ) VSUAL061GROUNDIX) 02 STOCK WATER MONITORINGF)WELLS TOY (( )1007VAPOR <br /> PRESSURESNIFF <br /> TESTWELLS <br /> ( )( 05 09 NONESENSOR 1NSTUMENT <br /> 0 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> ZF YOU CHECKED YES TO !V-F YOU APE NOT REWIRED TO CCMPLETE THIS SECTION <br /> Z) ol <br /> a <br /> TE CAS# (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> --- --� <br /> 0303030-3 <br /> ( ) 01 i ) 02 ( ) 03 1 <br /> ( 1 01 € } 02 t ) 03 <br /> Lf ) 02 [ ) 03 1 LL( ) 02 ( l 03 1 LL <br /> ( ) 02 ( l 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> EISCO:NT:AIN�ERLOC�ATED �AN RICULTURAL FARM? [ ) O1 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 /> PHONE W/AREA CODE <br /> PERSCNPILING (SIGNATURE) <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> ADMINZSTP.ATING AGENCY <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF L.457 INSPECTION iN COMPLIANCE <br /> PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />