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`w STATE ID NUMBER 00000018268001 <br /> CONTAINER CONSTRUCTION <br /> E. 1 ) 01 RUBBER LINED ( ) 02 ALKYD LINING 1 ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER= <br /> F. f ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING l ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE 05 SUCTION [ ) 06 UNKNOWN l ) 07 NONE <br /> VII LEAK DETECTION <br /> ( I <br /> 01 VISUAL (X) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( 105 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ] 07 PRESSURE TEST (X) 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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ! 01 f ) 02 ( ) 03 <br /> ( 1 <br /> 01 1 ) 02 ( ) 03 <br /> ( 101 f ) 02 f l 03 <br /> ( ) <br /> 01 ( ] 02 ( ) 03 <br /> f ) 01 ( l 02 ( ) 03 <br /> f 1 Ol ( 7 02 l ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> f ) 01 l ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 f ) 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AGRICUL RAL FARM? f ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN CPMPLETEO D,fiHE PE F J AND. 0 THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. qqq <br /> PERSON FILING (SIG ATURE PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AC MI NIST PATI NG GENCY CITY CODE COUNTY COD! <br /> CONTA&PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID A <br /> ( 7 01 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> / <br />