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STATE YD NUMBER 00000060123002 <br />f nMT TMCD f`nk)CTD"r TTnki <br />E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(1() 07 UNLINED I ) 08 UNKNOWN ( ) 09 OTHER) <br />F. ( ) 01 POLYETHLENE WRAP i ) 02 VINYL WRAPPING i )'03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br />( ) 06 TAR OR ASPHALT f ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) i ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE (X)-05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />t ) 01 VISUAL (X) 02 STOCK INVENTORY ( D 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />f ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIA -LS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES, TO IV -F YOU ARE NOT REQUIRED TO COMPLETE TRIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) - CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />f ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 0.3 <br />( ) 01 <br />f ) 02 <br />( ) 03 <br />( ) 03 <br />( ) 02 <br />( ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />(. ) 01 <br />f ) 02, <br />( ) 03 {{ <br />m <br />, <br />r <br />CHECK STATE BOA46 CHEMICAL CODEFOR POSSIBLE <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? i ) 01 YES (X) 02 NO <br />:ORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE PEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSON FILING (S NATURE) PHONE W/AREA CODE <br />ADMIN TPATING AGENCYCITY CODE COUNTY CODE <br />CONTACT PE SON PHO_NE W/AREA CODE <br />v <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />( ) 01 YES ( ) 02 NO <br />HSC04-070185 (10/18/85) <br />PAGE 2 <br />