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STATE ID NUMBER 00000038443001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ] 01 RUBBER LINED ( ) 02 ALKYD LINING ( ] 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNL NED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( J 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PPING . ( ] O1 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROP111ATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION f ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND P PING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROP IATE BOX(ES) ( ) 04 PRESSURE N 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER= <br /> VIII CHEMIC L COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CMECKE) YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> f 1 <br /> 01 ( ) �2 f 1 03 <br /> ( 1 Ol ( ) X02 ( 1 03 <br /> t ) <br /> al ( 1 p2 ( ) 03 <br /> [ 1 Ol ( ) 2 ( 1 03 <br /> O 01 11 2 f 1 03 <br /> ( ) 01 72 ( 1 03 <br /> f ) 01 ( ) 102 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) ,02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> r CHECK STATE �OARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> I <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 /> PERSON LING IGNATU P,E PHONE W A CODE <br /> ,01 <br /> I—d Z 3' �Rcj <br /> x <br /> FOR OCAL GENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> SRW oA mt 4 Lo�Rc� �rk� <br /> CONTACT P SON PHONE W/AREA CODE <br /> -Q6 F,- MkC-1+P, D0 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> f ) <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (1 /18/851 PAGE 2 <br />