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STATE ID NUMBER 00000062251004 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f l 04 PHENOLIC LlNING ( ) 05 GLASS LINING <br /> (X) -07 UNLINED- ( ) 08 UNKNOWN ( l 09 OTHER: <br /> F. ( ) 01 :POLYETHLENE WRAP (: ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION t ) 04 UNKNOWN 05 NONE <br /> 06 TAR OR ASPHALT ( ) 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING f ) 01 DOUBLE-WALLED PIPE ( D 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( )`'04 PRESSURE t l 05 SUCTION ( ) 06 UNKNOWN f } 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE E } e2 CONCRETE-.LINED TRENCH E ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE t 105 SUCTION t >) 06 UNKNOWN ( 107 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (XI 02 STOCK INVENTORY [ 104 VAPOR SNIFF WELLS E } 05 SENSOR INSTRUMENT g <br /> f ) 06 GROUND WATER MONITORING WELLS 07 PRESSURE TEST ( ) 09 NE 10 OTHER: ;%e, e <br /> VIZI CHEMICAL COMPOSITION OF MATERIALS STORED IN UNt3E- GROUND CONTAINERS <br /> =F YOU CHECKED YES TO TV-F YOU ARE NOT RE4UIR'SD TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 3 01 ( ) 02 ( ) 03 <br /> ( D 01 ( ) 02 ( ) 03 <br /> ( ) 01 d- l 02 ( ) 03 <br /> t ) 01 ( D 02 ( ) 03. <br /> ( ) 01 { ) 02 ( ) 03 <br /> f ) 01 f ) 02 ( ) 03 <br /> ( ) 01 t ) 02 ( ) 03 <br /> 01 E ) 02 ( ) 03 <br /> ( 101 t 102 ( ) 03 <br /> 01 ( J 02 ( ) 03 <br /> CHECK STATE 'BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYM <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM.HAS EEN COMPLETED UNDER THE PENALTY OF PERJURY AND', TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FIL NG (SIGNATUR r PHONE W/AREA CODE <br /> FOR LOCA. AGENCY USE ONLY <br /> AOMINISTR-ANG AGENCY CITY CODE COUNTY CODE <br /> 1 <br /> CONTACT 'PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION JIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 3,� 8 0 t J 01 YES ( T c02 NO <br /> MSC04-070185 (10/18/85) n '® � PAGE 2 <br />