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i <br /> STATE I0 NUMBER 00000014943014 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( l 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN f ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION f ) 04 UNKNOWN f ) 05 NONE <br /> f ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROU140 PIPING: - f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION f 1 06 UNKNOWN 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(E5) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN f l 07 NONE <br /> VII LEAK DETECTION <br /> l ) <br /> 01 VISUAL 1'�02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS DrT 07 PRESSURE TEST HtY09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF TERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-7 YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 <br /> al ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( l 01 f ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( l <br /> 01 ( ) 02 ( ) 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 MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGN URE) PHONE W/AREA CODE <br /> A 9- Fu;t-95 3S ° <br /> CJ <br /> FOR LOCAL AGEITCY USE ONLY <br /> ADMINISTPATI)?A A016,C UIN LOCAL HEALTH DISTRICT CITY CODE COUNTY COD! <br /> D . 3 <br /> CONTACT PERSON °�' PHONE W/AREA COD! <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL GATE TRANSACTION GATE LOCAL PERMIT ID # <br /> ( ) <br /> 01 YES f ) 02 ND <br /> HSC04-070185 (10/18/85) �•� <br /> PAGE 2 <br />