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• STATE ID NU,-,EER 00000020115 <br /> "CONTAINER CONSTRUCTION <br /> E. t d 01 RUBBER ,LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING [ ) 04 PHENOLIC LINING [ 1 05 GLASS LINING <br /> (X) C7 UNLINED i 1 08 UNKNOWN ( ) 09 OTHER' <br /> F. ( 1 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING [ 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN IX1 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING. C ) 01 DOUBLE—WALLED PIPE t 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXCES) f ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXCES) ( 1 04 PRESSURE (X) 05 SUCTION ( d 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> t ! 01 VISUAL C l 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS i ) 05 SENSOR INSTRUMENT <br /> 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE i l 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO !V-F YOU ARE NOT REQU=RED TO CCMPLETE THIS SECTION <br /> CUP=ENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( ) 01 ( ) 02 ( 1 03 <br /> f ) 01 t ) 02 ( 1 03 <br /> ( ) 01 4 ) 02 ( 1 03 <br /> ( ) <br /> 01 [ 1 02 [ 1 03 <br /> ( ) Cl ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 0.3 <br /> ( 1 01 [ ) 02 ( ) 03 <br /> 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 i l 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> EISCONTAIINE <br /> R LOCATED ON AN AGRICULTURAL FARM? t ] O1 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 /> SON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CCOE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> GATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( } O1 YES ( } 02 NO <br /> PAGE 2 <br /> HSC04-070185 (la/18/85l <br />