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STATE ID NUMBER 00000024934002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING { J 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN d 3 09 OTHERS <br /> F. ( ) 0.1 POLYETHLENE WRAP t l 02 VINYL WRAPPING 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 MORE <br /> t ) 06 TAR OR ASPHALT t ) 09 OTHER;: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING t ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE d ) 05 SUCTION t 106 UNKNOWN t -) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE t ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION t ) 06 UNKNOWN ( 3 07 NONE <br /> VII LEAK DETECTION <br /> { ) 01 VISUAL ( ) 09 STOCK INVENTORY t ) 04 VAPOR SNIFF WILLS t J 05 SENSOR INSTRUMENT <br /> { ) 06 GROUND WATER MONITORING WELLS t ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> I:F 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 /> t ) 01 O 02 O 03 <br /> ( ) 01 ( -I 02 ( ) 03 <br /> ( ) 01 { ) 02 t ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t ) 01 d )'02 ( ) 03 <br /> ) 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> { ) 01 { l 02 ( ) 13 <br /> t ) 01 ( ) 02 ( ) 03 <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 t NATURI PHONE W/AREA CODE <br /> FOR LOCAL QNCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION $N COMPL2ANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 02 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />