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1 <br /> STATE ID NUMBER 00000035194004 <br /> CONTAINER CONSTRUCTION <br /> FFt <br /> �11�RUBBERNED ( ) 02 ALKYD LINING C ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> D (X) 08 UNKNOWN f 1 09 OTHER: <br /> O1 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1' 03 CATHODIC PROTECTION [X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER' <br /> Vi WIPING <br /> A. ACHECKRAPPP.OPIIING.ATE BOX(ES) ( ( 01104OPRE55URELED PI05 SUCTION 02 CON NONE <br /> 7(NONE3 GRAVITY <br /> B. UNDERGROUND PIPING: [ ] 01 DOUBLE—WALLED PIPE C ] 02 CONCRETE—LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APFROPRIATE BOX(ES) [ ) 04 PRESSURE (X} 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> =0), <br /> L 02 5 K INVENTORY [ ] 04 VAPOR SNIFF WELLS [ ] 05 SENSOR INOSTRUMEEENT <br /> OUND TER MONI J ELLS ( ] 07 PRESSURE TEST JoA4-*4-"@ E <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO CCMPLETE THIS SECTION <br /> I <br /> Y Pn <br /> Y OELET€ GAS# [ZF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( ) 03( ) 03( ) 03( 1 03( ) 03 I ) 03( ) 03 LLLLLLLLLL- <br /> ( 1 03 <br /> C ] 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ] 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> E-1-S, ONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ] 01 YES (XI 02 NO <br /> THIS FORM HAS BEEN O LETED UNDER T 'PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PHONL AREA CODE f <br /> P€RSCN FILING i T � ,.... � a <br /> FOR LOCAL AGENCY SE ONL <br /> pIST• CITY CODE COUNTY CODE <br /> ACMINiSTRATING AGENCY <br /> PHONE WIAREA CODE <br /> /� (j Zs <br /> CONTACT PERSON �-^ �y�G,,/t (�/ 3 J <br /> Lr F LOCAL PERMIT IO u <br /> DATE OF LAST _NSPECT ON IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> 01 YES ( ) C2 NO <br /> PAGE 2 <br /> HSC04-070185 (1.0/18/85) <br /> • i <br />