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CONTAINER CONSTRUCTION STATE IO NUMBER 00000023438001 <br /> EE <br /> BER LINED ( 7 E) 09 <br /> LINING ( ) 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> UNLINED ( ) 08 ( 1 09 OTHER: <br /> YETHLENE WRAP INYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> TAR OR ASPHALT OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 03 GRAVITY <br /> l ) 05 SUCTION f ) 06 UNKNOWN f ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 7 02 CONCRETE-LINED TRENCH <br /> (CHECK APPROPRIATE BOX ( ) 03 GRAVITY <br /> BOX(ES) ( 7 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> s <br /> ( 1 <br /> 01 VISUAL ( 7 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE 1 ) 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) <br /> STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( ) 01 ( ] 02 f ) 03 <br /> f ) 01 ( 7 02 - f ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 l ) 03 <br /> f ) Ol ( 1 02 ( ) 03 <br /> ( 701 ( 702 ( ) 03 <br /> ( ] 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f 7 O1 ( ) 02 f ) 03 <br /> ( 101 ( ) 02 f ) 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 ENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FI (SIONATUR PHONE W/AREA CODE <br /> FOR LOCAL AGE Y USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) O1 YES ( ) OE NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />