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STATE ID NUMBER 00000045931005 <br /> CONTAIN€R CONSTRUCTION <br /> E. C 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING i ) 05 GLASS LINING <br /> (X) 07 UNLINED f 1 08 UNKNOWN i ) 09 OTHER: <br /> F. I ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT C l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) ,02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) I ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN C ) 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH C 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) C 1 04 PRESSURE IX) 05 SUCTION l 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL C ) 02 STOCK INVENTORY (X) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN, UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT PEq'JIPED TO COMPLETE THIS SECTION <br /> CURFENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STCPED STORED <br /> ( l 01 C 1 02 ( 1 03 <br /> ( ) 01 C 1 02 ( ) 03 <br /> ( l 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( 1 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> t 1 01 ( 1 02 ( 1 03 <br /> i ) 01 ( ) 02 ( ) 03 <br /> C l 01 t 1 02 f ) 03 <br /> ( ) OI t 1 02 C ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYM5 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (XI 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) PHON _W/ARCCCE <br /> FOR LOCAL A NCY USE ONLY <br /> ADMINISTRATING AGENCY fs� CITY CODE COUNTY CODE <br /> CONTACT PEFSON ) vci PHONE�W/�EA CODS <br /> d B U g /Z .r�'/ '/ "T j-7 3-6j z 'Z <br /> ._ <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # <br /> Y-? ( ) 01 YES C l 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />