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STATE ID NUMBER 00000001450001 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( / 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ] 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( l 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT l 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION l l 06 UNKNOWN ( l 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH (XI 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION f l 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> '` 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> y 4...""V-@95MrWATER MONITORING WELLS f 1 07 PRESSURE TEST (X) 09 NONE ( ) 10 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 CASA (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 f 1 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( ) O1 ( 1 02 ( ) 03 <br /> f 1 Ol ( ) 02 ( ) 03 <br /> ( ] <br /> 01 ( 1 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF NY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNAT PHONE W/AREA COD E9�_ /_ <br /> FOR LOCAL AGENCY USE ONLY d <br /> ADMIN17Z AGENCY f V IST1UC-_ CITY CODE COVNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> (fie I/L rn,P-,J <br /> DATE OF LAST INSPEFTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 6 01 YES ( 1 02 NO <br /> SSC04-070185 (10/18/85) PAGE 2 <br /> *Aw/ <br />