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STATE ID NUMBER 00000036048003 <br /> CONTAINER CONSTRUCTION <br /> E. ( } 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( } 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER- <br /> F. ( l Ol POLYETHLENE WRAP i ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( } 05 NONE <br /> ( } 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 OCUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(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 i l 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f )1) 0:6_OROUND <br /> ISUAL ( 1 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS I ) 05 SENSOR INSTRUMENT <br /> f WATER MONITORING WELLS [ ) 07 PRESSURE TEST (X) 09 NONE f ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT PEPUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STCPEO <br /> ( ) 01 ( 1 02 ( l 03 Q <br /> ( ) 01 E ) 02 ( ) 03 1 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( } 01 ( ) 02 ( } 03 <br /> ( l Ol ( ) 02 ( } 03 <br /> ( ) 01 ( ) 02 t ) 03 <br /> ( ) 01 ( ) 02 ( } 03 <br /> f ) 01 ( ) 02 ( 1_13 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> LZS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS EN MPLETED UNDER. THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> nFORR <br /> FILRLENCY <br /> ATUR '] PHONE W/AREA CODE <br /> ---- q e- i/l Ze <br /> 0 USE ONLY <br /> ADMINISTPATINC AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT .D # <br /> ( ) <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />