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STATE ID "NUMBER: 000.00042578001 <br /> CONTAINER CONSTRUCTION. <br /> E. t ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LININGS { ) 04 PHENOLIC LDd44G ( 3 05 GLASS LINING <br /> (X) r07 UNLINED ( ) US UNKNOWN <br /> ( 1 '09 OTHER= <br /> F. { ) 01`POLYETHLENE WRAP ;t } 02 VINYL WRAPPING (X) .03 CATHODIC PROTECTION.' { ) 04 UNKNOWN ( ) 05 NONE <br /> ( D 06 TAR OR ASPHALT { ) 09 OTHER; <br /> VI PIPING <br /> A. ABOVEGROUND P=IPING { ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXf•ES) ( ),04 PRESSURE ( ) 05 SUCTION { ') 06 UNKNOWN fx1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 0:1 DOUBLE-WALLED PIPE t 1- 02 CONCRETE-LINED TRENCH t D 03. GRAVITY <br /> {:CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE 0 SUCTION E' ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAS DETECTION <br /> t ) 01 VISUAL (X) 02 STOCK INVENTORY { .) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> t ) <br /> 06 GROUND WATER MONITORING WELLS 07 PRESSURE TEST t ) 09 NONE t l 10 OTHER' <br /> VIII CHEMICAL COMPOSITION" O-F "MATERIALS STORED IN UNDERGROUND CONTAINER <br /> IF YOV CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURP'ENTLY PREVIOUSLY DELETE CAS#. (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> E 1 01 ( ) 0"2 [ } 03 <br /> { ) 01 ( ) 02 t-D 03 <br /> f ) 01 ( ) 02 i„ l 03 <br /> ( ) 01 ( ) 02 ( } 03 <br /> 01 t l 02 { ) 03- <br /> )''al <br /> 33 Ol { ) 02 ( } 03 <br /> E ) 01 t ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( D 0"1 f ) 02 ( l 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 �LJNG (SIGNATUR- PHONE W/AR€A CODE <br /> FOR LO AL A-GENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY GODS <br /> CONTA T FFEEPS"C3' PHONE W/AR-EA CODL <br /> john c.- �_ _ ' <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> � 6 ( ) 01 YES ( ) '02 NO <br /> HSC64-070185 (10/18/853 PAGE 2 <br />