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STATE ID NUMBER 00000034920002 <br /> CONTAINER CONSTRUCTION <br /> Et ) <br /> RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING f ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> 07 UNLINED (X) 08 UNKNOWN f ) 09 OTHER: <br /> POLYETHLENE WRAP ( 102 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f 1 05 NONE <br /> 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL . 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> 1 06 GROUND WATER MONITORING WELLS (f07 PRESSURE TEST ( ) 09 NONE f l 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME) <br /> STORED STCPED <br /> I l 01 ( 1 02 ( ) 03 <br /> f ) <br /> al ( ) 02 ,. ( 7 03 <br /> ( 1 Ol ( 7 02 ( 7 03 <br /> ( T 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 f ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( 7 01 ( 7 02 ( ) 03 <br /> f ) O1 ( 102 ( 1 03 <br /> ( 1 <br /> 01 f ) 02 f 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 /> PE5RCV FILIN3 (SIG NATVR PZJ76e /AP A CODE <br /> FOR LOCAL AGENCY USE ONLY OBJ <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> S Soo_ ' z <br /> f �s <br /> CONTACT PERSON T(IL n VN 1A IfPHONE W/AREA CODE <br /> �CI�-33 -563 <br /> DATE OF LAST INSPECTION IN PERMIT .APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> �y... �6 ( ( ) 02 NO <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br /> L <br />