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STATE ID NUMBER 00000000724003 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED f ) 02 ALKYD LINING f l 03 EPDXY LINING f ) 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. l ) 01 POLYETHLENE WRAP l ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( 1 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN 9O 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X1 04 PRESSURE ( l 05 SUCTION ( l 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( 7 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 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 PP.EV=OUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( 101 l ] 02 f 1 03 <br /> [ ) 01 ( ) 02 f 1 03 <br /> f ) <br /> 01 ( 1 02 f 1 03 <br /> [ ) <br /> 01 ( 7 02 f ) 03 <br /> f ) O1 ( 7 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> 1 1 Ol ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> f l01 l 102 ( 103 <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 BEE MPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PE P.SON PILING (SI T E PHONE W/AREA CODE <br /> FOR LOCAL ENCY USE ONLY <br /> AOMINISTR.4TIN AGENCY CITY CODE COUNTY CODE <br /> CCNTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMRLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 O1 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />