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STATE ID NUMBER 00000007116002 <br /> CONTAINER CONSTRUCTION <br /> E.E <br /> BBER LINED ( ) 02 ALKYD LINING ( 103 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. LYETHLENE WRAP ( ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br /> TAR OR ASPHALT 1 ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 04 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED IPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (K4 OS SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> yl ) <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 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 AVE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STOPED <br /> f l 01 ( ) 02 ( 1 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( J 02 ( ) 03 <br /> ( ) O1 f 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 1 1 01 ( ) 02 ( ) 03 <br /> ( I <br /> 01 ( ! 02 ( ) 03 <br /> ( I <br /> 01 [ 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> iF 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 LPff R T E PENALTY Of PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING�.T$B{1 ATUR PHONE W/AREA CODE <br /> v <br /> FOR LOCAL AGEN 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 /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />