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STATE IO NUMBER 00000054840001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ! 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 7 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 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 ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( ) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASU fIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> X01 c l 02 ( ) 03 eros <br /> ( 1 O1 f l 02 O 03 I I I <br /> ( ) 01 ( 7 02 ( ) 03 <br /> 1 ) Ol ( ) 02 ( ) 03 <br /> ' 1 1 Ol f ) 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 f l 02 ( ) 03 <br /> ( 7 O1 f 7 02 ( ) 03 <br /> ( ) <br /> al ( 7 02 ( ) 03 <br /> ( ) O1 f 1 02 ( ) 03 <br /> .R 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_590PLETED UNDER THE PEN TY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> P SON IONATURE) PHOKE �- <br /> FOR LOCAL A NCY USE, ONLY <br /> ADMINS TP,AT IN3 GEMCY CITY CODE COUNTY CODE <br /> G �7 <br /> CONTACTLPERSON PHO E W/AREA CODE <br /> - <br /> DATE OF LAST INSPECTION IN COMPLIANCE FPM IT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID C <br /> ( ) 01 YES ( 1 OF NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />