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STATE ID NUMBER 00000031203002 <br /> CONTAINER CONSTRUCTION <br /> E. ( } 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04 PHENOLIC LINING C ) 05 GLASS LINING <br /> f ) 07 UNLINED (X) 08 UNKNOWN C ) 09 OTHER: <br /> F. C ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING t l 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> C ) 06 TAR OR ASPHALT i 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( l 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENC=H ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: C ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN C ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS C ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER: I?qb <br /> 5 <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS4 (IF KNO'wN) CHEMICAL (00 NCT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) O1 ( } 02 ( } 03 <br /> ( ) 01 t 1 02 ( ) 03 <br /> ( } 01 ( 1 02 1 ) 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> C ) 01 C ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> C ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 f ) 02 t ) 03 <br /> t } 01 ( 1 02 ( 1 03 <br /> ( } 01 C ) 02 C ) 03 <br /> ?� CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> [IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f )'01 YES CXJ 02 NO <br /> THIS FORM EN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> FEP.SO F N SIG E) PHONE W/AREA�rCO�DE <br /> J <br /> FOR LOCAL AGEN USE ONLY <br /> ADMINISTRATING_4,GENCY CITY CODE COUNTY CODE <br /> l <br /> CONTACT PERSON,- <br /> PH NEW AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />