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STATE ID NUMBER 0.0000012412002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) OB UNKNOWN d l 09 OTHERS <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTI (X) 04 UNKNOWN ( D 05 NONE <br /> ( ) 06 TAR OR ASPHALT { l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) { ) 04 PRESSURE { ) 05 SUCTION t : ) 06 UNKNOWN: ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( } 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ): 07 NONE <br /> VII LEAK DETECTION <br /> (�}t) 01 VISUAL tXJ 02 STOCK INVENTORY ( I 04 VAPOR SNIFF WELLS (' ) QVS SENSOR INSTRUMENT <br /> f J 06 GROUND WATER MONITMING WELLS ( ) 07 PRESSURE TEST t J 09NONE (X) 10 OTHER: LEAK DETECTOR <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( J 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> 0i t ) 02 ( ) 03 <br /> f 9 0�1 t ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( ) 0-1 ( ) 02 ( ) 03 <br /> 01 ( ),02 ( ) 03 <br /> { ) OI: ( ) 02 ( l 03' <br /> t ) 01 ( ) 02 ( ) 03 <br /> 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 Tt4E BEST OF MY KNOWLEDGE: IS TRUE AND CORRECT. <br /> PERSON LING (SIGNATURE): PHONE W/AREA CODE <br /> FOR LOCAL AGE iCY USE ONlY <br /> ADMINISTRATIN^ AGENCY. CITY CODE COUNTY CODE <br /> 4C I <br /> CONTACT PERSON- PHO-N W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES ( 1 02 NO <br /> HSC04-0701$S (10/16/65) PAGE:2 <br />