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STATE ID NUMBER 00000035811004 <br /> CONTAINER CONSTRUCTION <br /> E. C l 01 RUBBER LINED ( } 02 ALKYD LINING C 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ] 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. F 1 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( a 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING- [ ) 01 DOUBLE—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 C ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) [ 1 04 PRESSURE IX) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( D 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f 3 05 SENSOR INSTRUMENT <br /> i a 06 GROUND WATER MONITORING WELLS HE-r 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED _. <br /> ( ) 01 i ) 02 f 1 03 <br /> a 01 ( ) 02 E ) 03 <br /> ( ) 01 C 1 02 ( ) 03 <br /> ( ) <br /> 01 ( } 02 t a 03 <br /> ( ) <br /> 01 ( D 02 C ) 03 <br /> ( ) <br /> 01 f ) 02 ( D 03 <br /> t ) 01 F a 02 ( ) 03 <br /> [ 1 01 F } 02 ( ) 03 _ <br /> ( ) 01 F D 02 ( ) 03 <br /> ( 1 01 ( ) 02 i ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FCONTAINER LOCATED 014 AN AGRICULTURAL FARM? ( ) 01 YES (XI 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANDe TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> RERSO IL2 t _G TUR ) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ,ADMINISTRATING AGENCY CITb' CODE COUNTY CODE <br /> CONTACT PEPSON PHONE W/ARRA CODE <br /> DATE OF LAST INSPECTICN FiNCOMPLIANCE �02NO <br /> PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID)COMPLIANCE <br /> YES t ) <br /> HSCC4-070185 (10/18/85) PAGE 2 <br />