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0 • STATE ID NUMBER 00000012822002 <br /> CONTAINER CONSTRUCTION <br /> E. t 1 01 RUBBER LINED t ) 02 ALKYD LINING t ) 03 EPDXY LINING l ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER <br /> F. ( ) 01 POLYETHLENE WRAP f l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE f ] 02 CONCRETE-LINED TRENCH ( ) 03 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 ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE f 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) O1 VISUAL ( ) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST (X1 09 NONE t 1 10 OTH ER� <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 (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( 1 <br /> 01 t ) 02 ( ) 03 <br /> ( ) 01 [ 1 02 f ) 03 <br /> ( 1 Ol ( ) 02 ( 1 03 <br /> ( ) <br /> 01 f 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 Ol t ) 02 t ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ] 02 ( ) 03 <br /> ( ) O1 ( 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, I5 TRUE AND CORRECT. <br /> PEP.�. FI 0 TU ) PHON W/AREA CODE <br /> q 33�{-33a 1 <br /> FOR LOCAL AGEN Y USE ONLY <br /> ADMINISTRATING AGENCY I O A CITY CC� COUNTY CODE <br /> ( ` 3 <br /> CONTACT PERSON PNON E W/A�REA ODE -3 S6 <br /> DATE OF LAST INSPECTION IN PLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( ) 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />