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STATE ID NUMBER 00000014047002 <br /> CONTAINER CONSTRUCTION <br /> E. ( 101 RUBBER LINED ( 1 02 ALKYD LINING ( ] 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> f 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( l <br /> 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (4M 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CA$# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( 1 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Ol f ) 02 ( ) 03 <br /> l 1 Ol ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> [ ) Ol ( ) 02 l ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <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 BEE COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PER ON FILINO f ONATUR ) , PHON W/AR A CODE <br /> (r !a- D <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE <br /> Imf c lkwaff f iQ <br /> ODEQ COUNTY CODE <br /> CONTACT PERSO PHO W/AREA CODE <br /> y� <br /> DARE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID C <br /> ( ) 01 YES ( 1 02 NO <br /> 70185 (10/18/85) PAGE 2 <br /> `/ `/ <br />