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STATE ID NUMBER 00000011236004 <br /> CONTAINER CONSTRUCTION <br /> E. (X) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( l 04 PH€NOLIC LINING ( ) 05 GLASS LINING <br /> [ ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER' <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE f l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIP€ ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 4` ( UMENT <br /> 0106ISUAL GROUND(X) 02 STOCK WATER MONITORINGNTORYWELLS I( 11007VAPOR <br /> PRESSURESNIFF <br /> TESTWELLS( )(09 NONESENSOR) INST10 OTHER: <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 /> CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> I ] <br /> 01 ( 1 02 ( ) 03 <br /> ( ) Ol ( ) 02 ` ( 1 03 <br /> ( l 01 ( 1 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( 1 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( 102 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> ISCONTAINER LOCATED ON AN AGRICULTURAL FARM? l ) 01 YES (Xl 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 /> PERSON FIL (SIGN E.) PHONE W/AAR A CODE <br /> FOR L C L AGENCY USE ONLY V�✓✓ <br /> AOMINIST4O ' <br /> 1 <br /> 1 ` p_/S�� CITY CODE COUNTY CODE <br /> CONTACT PERS / T PHONE W/AREACOD <br /> u0► h� d J J <br /> DATE OF LAST IyyS P.ECTZON IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO 1t <br /> 1�3 � f 1 O1 YFS ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />