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0 <br /> STATE ID NUMBER 00000045931002 <br /> CONTAINER CONSTRUCTION <br /> E. f 1 01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING i } 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( 7 08 UNKNOWN ( l 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP € ) 02 VINYL WRAPPING ( 9 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( } 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: { ) 01 DOUBLE-WALLED PIPE l l 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE C } 06 UNKNCWN t ) rrMNE <br /> VII LEAK DETECTION <br /> f } <br /> 01 VISUAL C ) 02 STOCK INVENTORY (X) 04 VAPOR SNIFF WELLS ( } 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 YOU CHECKED YES TO _V-F YOU A;E NOT PEZUIPED TO COMPLETE THIS SECTION <br /> CUP.PENTLY PREVIOUSLY DELETE CAsn (IF VNOwNI CHEMICAL (DO NOT USE COMMEPCIAL NAME ) <br /> STOPED STCPED <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( l 01 C 1 02 ( 1 03 <br /> f 1 <br /> 01 ( ) 02 ( ) 03 <br /> { 1 01 ( 1 02 i 1 03 <br /> ( l 01 ( 1 02 ( 1 03 <br /> f 1 01 i 1 02 ( 1 03 i <br /> C } 01 ( 1 02 C 1 03 <br /> ( } 01 ( ) 02 ( ) 03 1 <br /> ( ) 01 f f 02 ( 1 03 <br /> ( ) <br /> 01 { ) 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN A.GRICULTUR.AL FARM"? ( } 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER TFE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> n-PSON FILING fSIGNATURE ) PHONE W•'APEA CODE <br /> �7 <br /> FOR LOCAL AGEN4 USE ONLY <br /> AOMINISTPATING AGNC'r7.' CITY CODE COUNTY CODE <br /> 1 J <br /> CONTACT PE S:JN ` IF PHONE W/APEA CODE <br /> DATE OF LAST-� INSDECTION IN COMPLIANCE PERMIT APPROVAL DATE �TRANSA:TZON DATE LOCAL PEP.MIT ID # <br /> 2� 4 <br /> — G 1 01 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> 0 <br />