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0 0 <br /> STATE ID NUMBER 00000045931006 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING { ] 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER* <br /> F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING [ ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( J 05 NONE <br /> (X) 06 TAR OR ASPHALT l ) 09 OTHER. <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINER TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES1 ( 1 04 PRESSURE (X) 05 SUCTION ( l 06 UNKNOWN E 1 07 NONE <br /> VII LEAK DETECTION <br /> t ) 01 VISUAL ( 1 02 STOCK INVENTORY (X) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED :ES TO IV-F YCU ARE NOT PEGU:PEO TO CCMPLE7E THIS SECTION <br /> CURRENTLY P=EVICUSLY DELETE CAS# (IF KNO'W'N) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STCRED <br /> ( 3 01 ( l 02 ( 1 03 <br /> ( 1 01 ( } 02 ( ) 03 j <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 { ) 02 ( ) 03 <br /> ( a 01 f ) 02 ( ) 03 <br /> ( ) 01 { 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) '13 <br /> ( 1 01 [ ) 02 [ ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINEP. 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 FILING (SIGNATURE) PHONE W/APEA CODE _5-02 7, <br /> � 'A 2-U f- y7 ' <br /> FOR OCAL AGE IY USE ONLY <br /> ADMT_NISTRATING A.GEN l' I,/ST CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 U <br /> 01 YES ( ) 02 NO <br /> HSC04-070165 (10/18/85) PAGE 2 <br />