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STATE 1D NUMBER 00000014943026 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING 1 l 05 GLASS LINING <br /> l ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION l l 04 UNKNOWN ( ) 05 NONE <br /> l ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CON RETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE [ l OS SUCTION <br /> ( 06 UNKNOWN ( l 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL W-02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) OS SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS 011 07 PRESSURE TEST •�!tLA9 NONE f ] 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 PPEVIOUSLY DELETE CASO (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 <br /> 01 t ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 f ) 03 <br /> f l Ol ( ) 02 ( ) 03 <br /> ( 1 Ol ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> f ) Ol ( ) 02 ( 1 03 <br /> ( I <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 1 ) 03 <br /> ( I <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> al ( ) 02 ( ) 03 <br /> a CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? l ) 01 YES (XI 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) PHON! W/AREA CODE <br /> FOR LOCAL AG CY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/ARCA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DAT! TRANSACTION DATE LOCAL PERMIT ID 0 <br /> 01 YES 1 7 02 NO <br /> HSC04-070185 O(10//188/85) /'�' PAGE 2 <br />