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40 40 <br /> STATE ID NUMBER 00000001276003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED t 102 ALKYD LINING ( ) 03 EPDXY LINING ( .) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN F l 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( i 02 VINYL WRAPPING t 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN t l 05 NONE <br /> fX) 06 TAR OR ASPHALT t 109 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: E ) 01 DOUBLE-WALLED RIPE t 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 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 { l 05 SUCTION ( ) 06 UNKNOWN t l 07 NONE <br /> VIZ LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> t ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT PEQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> t, l 01 ( ) 02 ( ) 03 <br /> ( 101 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 63 <br /> { L 01 ( ) 02 ( ) 03 <br /> t 101 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> E ) 01 t ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 r <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 PENALY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE: I5 TRUE AND CORRECT. <br /> PERS FILING t N R ) PHL)NE W✓AREA CODE <br /> t en <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRF.TI/iG AGENCY CITY CODE COUNTY CODE <br /> `a/ i% <br /> CONT TPERSON P NE W/AREA CODE <br /> i l� <br /> DATE OF LAST INSPECTION' IN COMPLIANCE ];;;MIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 #- <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />