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STATE ID NUMBER 00000045715001 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING [ ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 04 OTHER: <br /> F. i ) 0I POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( } 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: [ l 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> i (CHECK APPROPRIATE BOX ES) ( 1 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 04 NONE i ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPP'ENTLY PPEVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STOPED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> [ 1 01 [ } 02 ( } 03 <br /> ( ) 01 ( 1 02 ( l 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> f ) 01 ( ) 02 [ 1 03 <br /> ( l 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 COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE: IS TRUE AND CORRECT. <br /> PERSON FI�' GyTC� 7 PHONE W/AREA CODE <br /> FOR LOC L AGENCY USE ONLY <br /> .ADMINi TPATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT FEPSON PHONE W/ARE.A CODE <br /> DATE 1O1F LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 1 ( ) 01 YES ( 102 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />