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STATE ID NUMBER 00000014943024 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ).03 EPDXY LINING t ! 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION f ! 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) Ol 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• f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION f 1 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> f ) <br /> 01 VISUAL UKI 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS l l 05 SENSOR INSTRUMENT <br /> f ) 06 GROUNQ'=ER MONITORING WELLS CSO' 07 PRESSURE TEST CSO. 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( ) 02 ( 103 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( 1 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( l 03 <br /> ( l <br /> 01 ( ] 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( I <br /> 01 l ) 02 ( ) 03 <br /> f 1 <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 FILIN (SIGNATURE) PHONE W/AREA CODE <br /> 4 4 <br /> A4 4 <br /> Ll <br /> FOR LOCAL A ENCY USE ONLY <br /> ADMINISTRA NO AGENCY CITY CODE COUNTY OOE <br /> CONTACT PEPSON PHONE W/AREA CODE 3 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 # <br /> _ ( ) 01 YES f 1 02 NO <br /> HSC04-070185 (10/18/85) �'�' PAGE 2 <br />