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,mv mm <br /> STATE ID NUMBER 00000018913003 ; <br /> CONTAINER rONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING (J4 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> M 07 UNLINED ( ) OB UNKNOWN L!2.jLOTHER <br /> F. ( 7 O1 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION l ) 04 UNKNOWN (X) 05 NONE <br /> ( ) Of. TAR OR ASPHALT ( 7 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (OIECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f ) 05 SUCTION ( 7 06 UNKNOWN f ) 07 NONE <br /> R. UNDERGROUND PIPING f 7 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE f l 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII 'LEAK DETECTION <br /> ;1( , 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (A 07 PRESSURE TEST ( ) 09 NONE (j(') 10 OTHER: /-At .4epA I<Yrc h< f <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 /> CURRENCLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> SPORED STORED <br /> 01 ( ) 02 ( 1 03 <br /> ( I O1 ( ) 02 ( ) 03 I <br /> 01 ( ) 02 ( 7 03 <br /> (V ] <br /> 01 ( 1 02 ( ] 03 <br /> f 1 <br /> 01 [ 1 02 ( l 03 <br /> ( 1 Ol ( l 02 ( l 03 <br /> ( ) <br /> 01 ( ) 02 f l 03 <br /> ( 1 O1 ( ) 02 ( 1 03 <br /> ( 1 OL f ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR .POSSIBLE SYNONYMS <br /> IONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> ORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> FILING (S GNAA RE) n PHONE WW/ AREA CODE <br /> OCAL AGENCY USE ONLY <br /> (RATING AGENCY ` CITY CODE COUNTY CODE <br /> `ERGO PHONE W/AREACODE <br /> en� Y - 2- 3 <br /> \ST INSPECTION INCOMPLIANCE PERMIT APPROVAL GATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 011 YYEES�,,, ( 1 03 NO <br /> t <br /> (10/18/85) ^)^`^" 'fir ^� L r PAGE 2 <br />