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STATE ID NUMBER 00000023113002 <br /> CONTAINER CONSTRUCTION <br /> E <br /> UBBER LINED ( 1 02 ALKYO LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 7 UNLINED (X) 08 UNKNOWN [ 1 09 OTHER: <br /> OLYETHLENE WRAP ( 1 02 VINYL WRAPPINGf 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN [ ) 05 NONE <br /> 6 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 05 SUCTION ( 1 06 UNKNOWN l ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL PHJ 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS l ) 05 SENSOR INSTRLIME14T <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (� 1 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHICKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PP.EVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 <br /> 01 ( ) 02 ( l 03 <br /> l 1 01 ( ) 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> ( I O1 ( ) 02 ( ) 03 <br /> ( l <br /> 01 ( ) 02 f ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( 1 03 <br /> ( ] Ol f ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (XI 02 NO <br /> THIS FO M HAS BEETLSMPkETED UNC THE P ALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PE SC N3 SS 1 PX NE ARE y <br /> ODI _ <br /> UA <br /> FOR LOCAL AG CY USE ONLY <br /> AOMI N�NCY CITY COD! COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL OAT! TRANSACTION DATE LOCAL PERMIT ID # <br /> 1 ) <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />