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STATE ID NUMBER 00000038113001 <br />CONTAINER CUNSIKUGIIUIN <br />F.( <br />] 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 7 04 PHENOLIC LINING ( 1 05 GLASS LINING <br />( ] 07 UNLINED (X) 08 UNKNOWN l ] 09 OTHER) <br />1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f l 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br />( ) 06 TAR OR ASPHALT ( 109 OTHER( <br />VI PIPING <br />A (CHECK APPROPRIATE. BOX ES] ( ( 0104 PRESSURELEO P1PE 02 05 SUCTION CONCRETE -LINED( 06UNKNOWNTR(N) 07 NONE <br />3 GRAVITY <br />NONE <br />B UNDERGROUND PIPINGRIATE BOX(ES) ( ( 0104 PRE P�05 SUCTION IPE 02 CONCRETE -LINED 0KNOWNTRENCH07(NONE3 GRAVITY <br />tCH <br />CK <br />VII LtAK Ut <br />I tl.l <br />luN <br />( ) 01 <br />) 01 VISUAL <br />(X) 02 <br />STOCK INVENTORY <br />( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />;( <br />( ) 06 GROUND <br />WATER <br />MONITORING WELLS <br />( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />r.. ^Amar vTm TWTS SFGTTON <br />IF YOU <br />CURRENTLY <br />STORED <br />CHEOKEU Tea <br />PREVIOUSLY <br />STOPED <br />'v 1v 1 —..--- <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />t l 02 <br />( ) 03 <br />( ) 01 <br />f ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( 7 01 <br />t 102 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( 7 Ol <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( 7 02 <br />( ) 03 <br />( 1 01 <br />( 7 02 <br />( ) 03 <br />( ) 01 <br />( l 02 <br />( ) 03 <br />( ) 01 <br />l 1 02 <br />( ) 03. <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO I <br />mve TUP OPue(TY nP PFP.)OPY AND. TO THE BEST OF MY KNOWLEDGE, 25 TRUE AND CORRECT. <br />'EPSONFjWT�O (SIGNE <br />ATUR) PHp NE W/AREA CODE <br />(�a9) <br />or nui V <br />PAGE 2 <br />HSC04-070185 (10/18/85) <br />0 <br />ADMINI <br />A ENCV <br />lJI <br />CITO <br />COUNTY CODE <br />CONTAC <br />6:IG <br />PERSON 1 `rt'� <br />PHOt{E��E^ CgQE <br />Y <br />DATE OF <br />LAST INSPECTION <br />IN <br />COMPLIANCE <br />PERMIT APPROVAL DATE <br />TRANSACCTION <br />DATE <br />LOCAL PERMIT ID # <br />( <br />) 01 YES ( ) 02 NO <br />PAGE 2 <br />HSC04-070185 (10/18/85) <br />0 <br />