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STATE ID NUMBER 00000045099003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED f 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLA55 LTHING� <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER. <br /> F. [ l 01 POLYETHLENE WRAP [ 1 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION (X) 04 UNKNOWN t ) 05 NO'JE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLEDIPE f i 02 CONCRETE-LINEA TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( l 04 PRESSURE (y) 05 SUCTION ( 1 06 UNKNOWN f 1 07 NONE <br /> B. UNDERGROUND PIPING: i ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) C 1 04 PRESSURE (A) 05 SUCTION (X) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> [ ) O1 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( i 05 SENSOR INSTRUMENT <br /> ( ) Ob GROUND WATER MONITORING WELLS ( 9 07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED :sS TO IV-F `OU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE GAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED _J_ <br /> ( ) <br /> 01 C 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> f i 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ] 01 ( ) 02 t ) 03 <br /> f ) 01 f 1 02 ( 1 03 <br /> ( 1 01 C ) 02 ( l 03 <br /> f ) 01 f ) 02 ( ) 03 <br /> ( ! <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 /> F <br /> RSON FILING (YAGENCYft <br /> PHONE W/AREA CODE <br /> FOR LOCAL <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PEP.MIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) O1 YES ( l 02 NO <br /> HSC04-070185 (10/16/85) PAGE 2 <br /> �► <br /> 0 <br />