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• • STATE ID NUMBER 00000000953002 <br /> CONTAINER CONSTRUCTION <br /> E ( 1(01 07BUNL INEDEO(X) 02 ALKYD 08 UNKNOWN LlNIN09 OTH ER3 EPDXY LINING ( ] 04 PHENOLIC LINING ( 1 OS GLASS LINING <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: ' <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH <br /> 07(N) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE 05 SUCTION � N <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL p<S-2 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUNDWATER MONITORING WELLS ( ) 07 PRESSURE TEST 4X+-e""0!(� <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES T0. IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPRENT LY PkEVIOUSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 f 1 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 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 CO PLETED DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PHONE W/.4RE�COOE n,� v- <br /> PERSON FILIN3 (SIG ) /(+JVV�{ UX <br /> FOR LOCAL A NCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> ADMINISTRATING5;t1i( jZa14QI4iAI LdGAjti <br /> /\ <br /> PHONE_W/AREA CODE � �� <br /> CONTACT PERSON a1 �/G /!J//�') - <br /> � Od LOCAL PERMIT IO # <br /> jOATE OF LAST IN CTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> OOyy ( ) 01 YES ( 1 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />