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STATE ID NUMBER 00000054432002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RU6BER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 06 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 7 02 VINYL WRAPPING ( 103 CATHODIC PROTECTION ( 7 04 UNKNOWN f ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOM ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING-• ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 1 ] 01 VISUAL ( ) 02 STOCK INVENTORY f 7 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 ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( l 01 f 7 02 ( l 03 <br /> ( l 01 ( 7 02. ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> f ] 01 [ 1 02 ( l 03 <br /> ( 101 ( 1 02 ( 1 03 <br /> R 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 HA Y9EN PLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FI ( I TUPE) PMON ARF CODE - ' <br /> FOR LOCAL NC✓YUSE ONLY ��Ll <br /> ADMINISTRATING AGENCY 11 '' / CITY CODE COUNTY CODE <br /> �G( ) H-ea TY'(c 39 1 <br /> CONTAI'5 PERSON PH NE W/AR COD! <br /> zeL� :; 9 y- 7311 <br /> DATE OF LA T INSPECTION IN COMPLIANCE PERMIT APPROVAL DAT! TRANSACTION DAT! LOCAL PERMIT IO # <br /> ( ] O1 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> \ w <br />