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STATE ID NUMBER 00000028380001 <br /> CONTAINER CONSTRUCTION <br /> E(X) <br /> ETAR <br /> NED [ l 02 ALK�� L(N)N09 OTHER.3 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> D ( ) 08 UNKNOENE WRAP (())0249VIONLRWRAPPING t ] 03 CATHODIC PROTECTION ( ) 04 UNKNOWN EX) 05 NONE <br /> R ASPHALT <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE 80X(E5) ( ) 04 PRESSURE ( ) 05 SUCTION E ) 06 UNKNOWN E ] 07 NONE <br /> B. UNDERGROUND PIPING ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( l 44 PRESSURE tX) 05 SUCTION ( 1 46 UNKNOWN t l 07 NONE <br /> VII LEAK DETECTION <br /> ( l LLS SENSOR INSTRUMENT <br /> VISUAU ROU 01 ( ) 02 STOCK INVENTORY <br /> ) 0VAPOR <br /> SNIFF <br /> 06 NDWMONITRING 07PRESSURETESTl09 NO HER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS PSE STORED SEN$UNDERGROUND CONTAINERS <br /> IF YOU CH=GKED YES TO IV-F YOU ARE NOT REQUIRED TOU <br /> CURRENTLY ?REVIOUSLY DELETE CAS. (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOP°D <br /> t ) 01 ( ) 02 ( 1 03 <br /> ( l 01 ( l 02 ( ) 03 <br /> 11 _LLI <br /> { ) 01 ( l 02 ( ) 03 <br /> f ) 01 ( ) 02 E ) 03 <br /> ( l 01 ( 1 02 ( ) 03 <br /> t ) 01 1 ) 02 ( ) 03 <br /> t ) 01 ( ) 02 f ) 03 <br /> ( ] 01 [ l 02 ( ) 03 <br /> ( ) 01 [ ) 02 ( ) 03 <br /> E ) 01 [ ) 02 E ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL 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 /> PERSON FILING tSiGNATUR , B <br /> FOR LOCAL AGENCY USE f�ZONLY csrr cane JJ COUNTY CODE <br /> AOM��STR�'�G AGENCY / /f /J-f}-1�?�� <br /> j� pmoNE W/AARE r CODE <br /> CONTg2T Pf SQN �d?� (J��d �T� �/ <br /> / <br /> /J/y LOCAL PERMIT ID # <br /> 04TE CF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> 1 01 YES [ ) 02 NO <br /> O 1� PAGE <br /> HSC04-070185 (10/18/85) <br /> • <br />