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STATE IO NUNEER 00000004741004 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED t 1 02 ALKYD LINING ( ) 03 EPDXY LINING r ) 04 PHENOLIC LINING r l 05 GLASS LINING <br /> (X) 07 U){LINED ( 1 08 UNKNOWN t ) 09 OTHER: <br /> F. ( ) 01 POLYETHLEHE WRAP ( 1 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( J 05 NONE <br /> ( ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( } 02 CONCRETE-LINED TRENCH f ) 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 f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X1 04 PRESSURE ( ) 05 SUCTION f ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> r ) 01 VISUAL (X1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 Ob GROUND WATER MONITORING WELLS i ) 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 PEPUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PPEVIC'JSLY DELETE CAS# CIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> l 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> r 1 01 c } 02 ( ) 03 <br /> i 1 01 f ) 02 i ) 03 <br /> i 1 01 ( 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 13 <br /> ( ) 01 ( } 02 f ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER 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 /> ?EPSON FILING fSIGNAT 1 <br /> ::: PHONE W�ARE.4 CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY �S� CITY CODE COUNTY CODE <br /> S" j, IN) Lac vi l A N <br /> CONTACT PERSON PHONE W/ARE.A CODE <br /> S <br /> DATE OF LAST INSPECTION IN COMPLIANCE------------ PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT dD # <br /> ( ) OI YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />