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0 s <br /> STATE ID NUMBER 00000042134007 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING (X) 03 EPDXY LINING ( 1 04 PHENOLIC LINING i ) 05 GLASS LINING <br /> ( ) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER. <br /> F. f ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) D3 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN f l 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL_ COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED 'TES TO IV-F YOU APE NOT PE-UIPED TO CCMPLETE THIS S-ECTION <br /> CURRENTLY PREVICUSLY DELETE CASz (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STOPED STORED <br /> (X) 01 ( ) 02 ( ) 03 1 0 8 8 8 3 * TOLUENE (METHYLBENZENE,AROMATIC HYDROCARBON LOW ANALINE) <br /> ( ) 01 ( ) 02 :: ( ) 03 <br /> i 1 01 ( l 02 ( ) 03 <br /> t 1 O1 { J 02 t ) 03 <br /> f ) 01 { ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 i ) 03 <br /> I 1 01 f ) 02 ( ) 03 <br /> ( ) 01 [ ) 02 ( l 03 <br /> ( 1 01 ( ) 02 { l 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FCONTAINER 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 FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CON74CT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION �INCOM�PLIANCE PEFMIT .APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID a <br /> HSC04-070185 (10/18/85) PAGE 2 <br />