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STATE ID NUMBER ()0008062853003 <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING E ) 04 PHENOLIC LINING E ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN { ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION t ) 04 UNKNOWN (X) 05 NONE <br />( ) o6 TAR, OR ASPHALT ( ) 09 OTHER: <br />&�avalll <br />A. *a «a 01 as a a aGRAVITY <br />APPROPRIATE a 0. PRESSURE.SUCTIONa • <br />UNbfAGROUNtl # .e a PIPE dt tONCRfTE—LruED TRENCH o3 GRAVITY <br />,..aeon B 04 .. a 4 6' SUCTION ( A 66 a 07 S <br />VII: LEAK DETECTION <br />t 0.1 VISUAL (X) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS { ) 05 SENSOR INSTRUMENT <br />E ) 06 GROUND WATER MONITORING WELLS 07 PRESSURE TEST' ( ) 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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />c 1 <br />(:) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />(; ) 03 <br />( )01 <br />( )02 <br />€ .)03 <br />t ) 01 <br />( ) 02 <br />( l 03< <br />01 <br />( ) 02 <br />( ) 03 <br />( ) 01_ <br />( ) 02 <br />( ) 03 <br />l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( 3 01 <br />(; ) 02 <br />( ) 03 <br />CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINERLOCATEDOhl'AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br />THIS FORM S BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE: IS TRUE AND CORRECT. <br />PERSON F lI O CSIGNATUR PHONE 14/AREA CODE <br />FOR LOCAL AGENCY USE =ONLY <br />ADMINISTRATING AGENCY' ® CITY CODE <br />:50j) I <br />CONTACT PERSON PRONE W/AREA CODE <br />C '5- <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br />C J 01 YES ( ) 02 NO <br />HSC04-070185 (10/18/45) <br />CODE <br />L PERMIT ID # <br />PAGE 2 <br />