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STATE IO NUMBER 000000083.32005 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( } 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: <br /> F. 1 ) 01 POLYETHLENE WRAP i ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION t ) 04 UNKNOWN ( 1 05 NONE <br /> tX) 06 TAR OR ASPHALT ( 1 09 OTHER. <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE i ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL ( ) 02 STOCK INVENTORY t D 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER' <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT PEgUIFED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NATE) <br /> STOPED STORED <br /> ( ) <br /> 01 t ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ] 03 <br /> ( ) 01 ( ) 02 f l 03 <br /> ( l 01 ( l 02 ( 1 03 <br /> f 1 <br /> 01 ( ) 02 i ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( 1 01 f ) 02 ( l 03 <br /> t 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( 1 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 BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON 451GN R ) PHON- W/AREA CODE <br /> FOR LOCAL AGENUSE ONLY <br /> ADMINISTPATIN AGENCY A ` ' CITY CODE COUNTY CODE <br /> CONTACT REP ON r PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPL14NCE PERMIT .APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( ) 01 YES ( ) C2 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />