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STATE ID NUMBER 00000023617002 <br /> CONTAINER CONSTRUCTION <br /> E <br /> 1 076UNLINEOBER EO(X1 OBoZ ALKYD UNKNOWN LININ 09 OTHER3 EPDXY LINING04 PHENOLIC LINING [ ) 05X1LOS NONEIN1 06LTARNORNASPHALT [f))02 VINYL WRAPPING ( 103 CATHODIC PROTECTION l 1 04 UNKNOWN <br /> VI PIPING <br /> A. <br /> AS <br /> PIPING ( ) O1 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVIT <br /> (CHECK APPROPRIATE BOXIE31 ( ) 04 PRESSURE [ 1 05 SUCTION l ) 06 UNKNOWN ( ) 07 NONE <br /> S-. UNDERGROUND PIPING [ 1 Ol DOUBLE-NALLED�PIPE [ ) 02 CONCR C) UN NOD TRENCH l ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE C 05 SUCTION (3F1' 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> NSTR <br /> ( ( ENT <br /> ) 06I <br /> IGROUND(WATER MONIT RINGNWELLS (I1)007VAPOR <br /> PRESSURESNIFF <br /> TESTWELLS t EN <br /> VSUALX) 02 STOCK INVETORY )[09 NONE ( ) 10 OTHER: <br /> VII' YDCHEMIKCEA LESCOMPOSITIO TO IV-P YOU E OF REQUIRED ro cS STORIED IS SECTION IDUNDERGROUND CONTAINERS <br /> CURRENTLY PREVIOUSLY DELETE CAS# (SF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f 1 01 ( ) 02 I 1 03 <br /> f ) <br /> 01 f ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( 1 03 <br /> ( 1 Ol ( 1 02 f ) 03 <br /> ( 1 Ol ( ) 02 ( 1 03 <br /> f l <br /> 01 ( ) 02 f ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol f ) 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> t l <br /> 01 ( ) 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 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 FI G (SIG URE) HO /AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING ky$NCY CSTY C DE COVNTY CODE <br /> VT <br /> CONTACT PERSON 4 PH NE W/ REA CODE <br /> GATE OF LAST INSPECTIN I <br /> ON COMPLIANCE <br /> ( ) 01 YES PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( ] 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />