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\.. .� <br /> STATE ID NUMBER 00000008496002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED f ) 02 ALKYD LINING f 1 03 EPDXY LINING f ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING [ ] 03 CATHODIC PROTECTION (X) 04 UNKNOWN l ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING' ( ) 01 DOUBLE-WALLED PIPE [ 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 P1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ] 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> f ) 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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 f ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> f ) Ol ( ) 02 f ) 03 <br /> l ) 01 ( 1 02 ( ) 03 <br /> l ) <br /> 01 f ) 02 [ ) 03 <br /> f ) 01 f ) 02 ( ) 03 <br /> ( I <br /> 01 f ) 02 ( ) 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS 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 CORRECT. <br /> PERSON ILING ($I NAT P. PH NE W/ CODE <br /> F LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY I CITY CODE COUNTY CODE <br /> 'UoWa fit _7501 1 <br /> CONTA T PERSON PH N! /AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />