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STATE ID NUMBER 00000013082001 <br />CONTAINER CONSTRUCTION <br />E. ( ] 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f l 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. f 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION f ) 04 UNKNOWN ( ) 05 NON <br />(X.) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( <br />1 01 DOUBLE -WALLED <br />PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />( ) 03 <br />(CHECK APPROPRIATE BOX(ES) <br />( ) 04 PRESSURE ( <br />) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 <br />NONE <br />INSTRUMENT <br />S. UNDERGROUND PIPING: ( <br />) 01 DOUBLE -WALLED <br />PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />) 09 NONE (X) <br />(CHECK APPROPRIATE BOX(ES) <br />( ) 04 PRESSURE (X) 05 <br />SUCTION <br />( )06 UNKNOWN ( ) 07 <br />NONE <br />( ) 03 <br />VII LEAK DETECTION <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />CITY CODE <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />rl /yll�/1Q <br />( 1 01 VISUAL <br />(X) 02 <br />STOCK INVENTORY f <br />104 VAPOR SNIFF WELLS <br />( ) 05 SENSOR <br />INSTRUMENT <br />( ) 03 <br />PERMIT APPROVAL <br />f ) 06 GROUND <br />WATER <br />MONITORING WELLS ( <br />1 07 PRESSURE TEST ( <br />) 09 NONE (X) <br />10 OTHER: CHECKED FOR WA <br />ER BY <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINER <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 />CITY CODE <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />rl /yll�/1Q <br />( ) 01 <br />( ) 02 <br />( ) 03 - <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />PERMIT APPROVAL <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />PERMIT IO # <br />( Y 01 <br />( ) 02 <br />( ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />f l 01 <br />( ) 02 <br />( 1 03 <br />1 O1 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />I JIS 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 KNOWLEDGE, IS TRUE AND <br />PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMI STRATING AGENCY <br />CITY CODE <br />COUNTY CODE <br />CON ACTPER50 <br />0( oor � , Carel, <br />rl /yll�/1Q <br />f^ <br />P NE /AREA CODE <br />?09� kzr_T2_ - <br />DATE OF LrAST INSPECTION <br />Q-/sem�� <br />IN COMPLIANCE <br />(;<) 01 YES ( ) <br />02 NO <br />PERMIT APPROVAL <br />DATE <br />TRANSACTION DATE <br />LOCAL <br />PERMIT IO # <br />I HSC04-070185 (10/18/85) I PAGE 2 <br />