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STATE ID NUMBER 00000060123003 <br />cnNTATN ..CONSTRUCTION` <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ).02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f 1 05 SUCTION ( 106 UNKNOWN t 107 NONE <br />B. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />d } O1 VISUAL (X) 02 STOCK INVENTORY ( 104 VAPOR SNIFF WELLS ( )05 SENSOR INSTRUMENT <br />106 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIAL'S STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU ARE NOT REgUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IR KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />101 <br />t 3 02- <br />( 103 <br />(') 01 <br />( ) 02 <br />( 1 03 <br />( ) 01 <br />( D 02 <br />( ) 03 <br />( 1 01 <br />( } 02 <br />( 3 03 <br />( } 01 <br />{ } 02 <br />1 1 03 <br />D 01 <br />( ) 02 <br />( D 03 <br />( 101 <br />( ) 02 <br />( 1 03 <br />1 01 <br />( ) 02 <br />( ) 03 <br />(} 01 <br />( ) 02 <br />( 1 03 <br />} 01 <br />( ) 02 <br />( ) 03 <br />A CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO I <br />S FORM; HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PEPSON ItIN6 CSIGNATURE) 2 PHONE W/AREA ODE <br />n <br />*9 LOCAL A ONLY <br />ADMINITPATIN9,_AJGZNCYCITY CODE COUNTY CODE <br />L <br />,CONTACT PERSON PHO E W/A EA -CODE <br />f <br />DATE OF LAST INSPECTION JIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE ]LOCAL PERMIT ID # <br />( ) 01 YES C d 02 NO <br />HSC04-070185 (10/18/85) PAGE 2 <br />