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CONTAINER CONSTRUCTION STATE ID NUMBER 00000019742002 <br /> E. 1 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 BLABS LINING <br /> f 7 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> [A.* ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION f 1 06 UNKNOWN 1 ) 07 NONE <br /> UNDERGROUND PIPING [ ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL <br /> IF YOU CHECKED COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) Ol ( 7 02 ( ) 03 <br /> f ) Ol ( J 02 ( ) 03 <br /> f 1 01 ( l 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 7 03 <br /> ( ) 01 f 1 02 ( ) 03 <br /> f ) 01 f ) 02 f ) 03 <br /> ( 'l <br /> 01 ( ) 02 ( ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) <br /> PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> FOATE <br /> ISTRATING AGENCY <br /> CITY CODE COUNTY CODE <br /> CT PERSON <br /> PHONE W/AREA CODE <br /> OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( ) O1 YES ( ) 02 NO LOCAL PERMIT ID # <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br />