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STATE 10 NUMBER 00000040920001 <br /> CONTAINER CONSTRUCTION <br /> E. t ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: — <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> 1 06 TAR OR ASFHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( 1 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (SX) 01 VISUAL (yQ 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED YES TO IV-F YCU APE NOT REQUIRED TO COMPLETE THIS SECTICN <br /> CURRENTLY PPEVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STCC,O STORED <br /> ( ) of ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( i 02 ( 1 03 <br /> ( } 01 ( l 02 1 1 03 <br /> ( ) 01 f ) 02 f ) 03 <br /> f ) 01 ( 1 02 ( l 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> f } 01 ( ) 02 ( ) 03 <br /> 4 1 <br /> 01 i ) 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN C5911,PED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PE- 0. FILI. (S GNA R ) PHONE W/AREA CODE <br /> - � 2sa�r S -SS d <br /> FOR LOCAL AGEN USE ONLY <br /> AOMIN*STPATIN AGENCY l CITftPHCNE <br /> COUNTY CODE <br /> ©gtl L tY <br /> CONTAT PERSC W/AREA CODS <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE JTRANSACTICN DATE LOCAL PERMIT IO # <br /> ( ) 01 YES ( 3 02 NO <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br />