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0 <br /> STATE ID NUMBER 00000010516001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( 1 07 UNLINED (X) 08 UNKNOWN i ) 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( i 05 NONE <br /> ( l 06 TAR OR ASPHALT i 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING= ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXiES) ( ) 04 PRESSURE ( ) 05 SUCTION t ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING' t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE I.05 SUCTION H,-) 06 UNKNOWN t 1 07 NONE <br /> VII LEAK DETECTION <br /> ( l 01 VISUAL ( 1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( l 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> .TF YOU CHECKED YES TO IV-F YOU ARE NOT REUIPEO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS4 (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t ) <br /> al ( 1 02 ( 1 03 <br /> ( ) 01 ( 1 02 t 1 03 <br /> 1 01 i ) 02 ( ) 03 <br /> ( ) 01 i ) 02 ( ) 03 <br /> t J 01 ( ) 02 ( 1 03 <br /> t J <br /> 01 ( 7 02 i 1 03 <br /> t ) 01 ( l 02 ( ) 03 <br /> ( l 01 i 1 02 ( ) 03 <br /> t J 01 ( ) 02 ( 1 03 <br /> ( ) 0l ( ) 02 ( ) 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 EEN COMPLETED NDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> [P E ON F T SIGNATURE PHO 7A C <br /> L <br /> FOR LOCALS GENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON [PHONE W/APEA CODE <br /> DATE OF LAST INSFECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID <br /> ( l 01 YES ( l 02 NO <br /> HSC04-070185 (10/18/85) <br /> F <br />