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%MOOSTATE ID NUMBER 00000013964001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUEUNLIEKED (Xi <br /> ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( 1 07 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( 1 O1 PORAP [ J 02 VINYL WRAPPING ( } 03 CATHODIC PROTECTION (X) 04 UNKNOWN [ l 05 NONE <br /> 06HALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION t 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: [ ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( } 04 PRESSURE tX) 05 SUCTION [ ) 06 UNKNOWN ( 1 07 NONE, <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY t l 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS i } 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REOUIBED TO COMPLETE THIS SECTION <br /> CU;F5NTLY PREVIOUSLY OELETE CAS# (IF XNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STCRED STORED <br /> ( 1 01 ( l 02 ( 1 03 <br /> ( 1 01 ( 1 02 [ 1 03 <br /> t ) Ol t } o2 ( } 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( ) 01 E 3 02 ( 7 03 <br /> ( J 01 ( ) 02 [ ) 03 <br /> [ } 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 t ) 03 <br /> ( l <br /> 01 ( ) 02 t 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FISCONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANOp TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> FEP.SCN FILING (SIGNATUPE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AZMlNISTRATZNG AGENCY CITY CCDE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CCDE <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPPOVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) O1 YES ( S 02 NO <br /> HSC04-070185 (10/18/851 PAGE 2 <br />