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STATE IO NUMBER 00000068174001 <br /> CONTAINER CONSTRUCTION <br /> E ( 1(07 RUBBER LINED( 1 08 UNKNOWN LINING <br /> 09 OTHER' <br /> EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> 07 <br /> NED <br /> F. ( 1(07 OLTARHORMASPHALT E WRAP (()1D09VINYL <br /> WRAPPING ( 1 03 CATHODIC PROTECT <br /> ION ( ) 04 UNKNOWN ( 1 05 NONE <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l 1 O1 DOUBLE-WALLED PIPE l l 02 CONCRETE-LINED TRENCH 03 GRAVITY <br /> [ ) <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( ) OS SUCTION ( 1 Ob UNKNOWN 07 NONE <br /> ( 1 <br /> ( 1 01 DOUBLE-WALLED IPE ( 1 02 CONCRETE-LINED TRENCH l 1 03 GRAVITY <br /> B. UNDERGROUND PIPING' <br /> ( ) 04 PRESSURE 05 SUCTION ( ) Ob UNKNOWN l 7 07 NONE <br /> (CHECK APPROPRIATE BOX(ES) <br /> VII LEAK DETTE,�/CCTIONEETT <br /> ( ` 010VIGROUNO WAIiR SMONITORINGENNWELLS ((l1 07VPRPPESSUREFTESTLLS 1(09 NO55 NEENSOR lOSOTFIER <br /> VIII CaMICAL sOoPOSITIO N OF <br /> MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> vYeIREQUIRED ETTHIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# IIF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) O1 ( l 02 l 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 l 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( 7 01 ( ] 02 ( ] 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 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 /> PHONE W/AREA CODE ' _-7/O �i <br /> PERSD F L (SIGNATURE) G / <br /> FOR 0 AL AGENCY E ONLY COUNTY CODE <br /> CITY CODE <br /> ADMINISTRATING AGENCY <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> LOCAL PERMIT ID # <br /> ( ) O1 YES ( ) 02 NO <br /> PAGE i <br /> HSC04-070185 07/03/871 <br />