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0 0 <br /> 5TATE ID NUMBER 00000031688001 <br /> CONTAINER CONSTRUCTION <br /> V <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f ) 04 PHENOLIC LINING [ ) 05 GLASS LINING <br /> { ) 07 UNLINED (X) 08 UNKNOWN f ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP { ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( T 04 UNKNOWN tXT 05 NONE <br /> ( ) 06 TAR OR ASPHALT l ) 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 ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN { ) 07 NONE <br /> VTI LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIP.ED TO COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CAS'# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STOPED STORED <br /> ( ) 01 ( ) 02 ( ) 03 _ - <br /> ( ) cl ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( 1 03 <br /> Hl <br /> i ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( l O1 ( 1 02 t ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES (X) 02 NO <br /> THIS FORM BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PER , FINl f S U,PE)`/ PHONE W/AREA CODE <br /> FOR LOCAL AGE NUSE ONLY 4-,— <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> lj'W )s_75)40" zagm, bb7rejrt__ <br /> (CONTACT PERSON PHONE <br /> /W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATETRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />