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STATE ID NUMBER 00000052242001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER= <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 uwNOWN ( ) 05 NONE <br /> ( 7 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 7 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f 1 O1 ( ) 02 ( ) 03 <br /> ( 1 01 ( l 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> ( ) 01 ( 7 02 ( ) 03 <br /> [ 1 <br /> 01 ( 1 02 ( ) 03 <br /> t ) O1 I 1 02 ( ) 03 <br /> f 1 01 ( 1 02 ( ) 03 <br /> l l <br /> 01 ( ) 02 f ) 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> R CHECK STATE BOARD CHEMICAL COVE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORAHASE LETED UND R THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PE SON R PHONE W/AREA E <br /> FOR LY SE LY <br /> ADMINISTRATING AGENCY / CITY CODE COUNTY COD! <br /> JRW, ( ��T <br /> CONTACT PERSON PHONE W/ REA CODE <br /> a <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL GATE TRANSACTION DATE LOCAL PlRMIT ID S <br />\ f 7 <br /> 01 YES ( 1 02 NO <br /> [C04-070185 (10/18/85) PAGE 2 <br />