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STATE ID NUMBER 00000005737001 <br /> CONTAINER CONSTRUCTION <br /> E ( )(X)01 RUBBER LINED( ) 08 UNKNOWN LININ09 ( 3 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) OS GLASS LINING <br /> 07 <br /> NED <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN t ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER <br /> VI PIPING <br /> A ABOVECROUNDRIATE <br /> ( ( 0104oPRESSURELEO P105 SUCTION PE 02 CONCRETE-LINED 06UNKNOWNTREN)H 07(NONE <br /> 3 GRAVITY <br /> B UNDERGRAPPROPPIPING: <br /> BOX(ES) ( ( 0104 DOUBLE-WALLED <br /> PRESSURE XI 05 SUCTION IPECONCRETE-LINED 06EUNKNWNTR`N)H 07(NONE 03 GRAVITY <br /> CK <br /> RIATE <br /> VII LEAK DETECTION <br /> ( ( 0106VSUALIGROUNONSTRUMENT <br /> (WAT02 STOCK ER MONITORINGINVENWEL LS ((1)007V PR ESSUR ESNIFF <br /> TESTWELLS )(09 NONEENSOR 10 OTHER: <br /> 05 VIII CHEMICoLSOMPOSITIO COMPOSITION MATERIALS OR„D IN UNDERGROUND CONTAINERS <br /> vEREQUIRED COMPLETESID <br /> CURRENTLY PREVIOUSLY DELETE CAStt (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 [ ) 02 t ) 03 <br /> ( ) <br /> 01 ( 1 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 t ) 02 ( 1 03 <br /> ( 1 <br /> 01 ( l 02 ( 1 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 l ) 02 t ) 03 <br /> [ ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 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 /> PHONE W/AREA CODE <br /> PERSO IL NO. IO, TUBE) <br /> m <br /> NCY USE ONLY 0- <br /> A ' CITY CODE COUNTY CODE <br /> CY LO 1\ /1 -A1- JJQPMON} aZcl OOD ! - �((� l ll d-JCT)\IO IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( ) 01 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />