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' # v <br /> �. %W r./ STATE I0 NUMBER 00000035002006 <br /> CONTAINER CONSTRUCTION <br /> EFt <br /> 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> O1 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN f 1 05 NONE <br /> ) 06 TAR OR ASPHALT l ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH fief 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING' ( ) 01 DOUBLE-NALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE y OS SUCT ( ) 06 UNKNOWN f ] 07 NONE <br /> VII LEAK DETECTION <br /> �( 1 <br /> 01 VISUALfXj ) D' ST"K TWV NTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (XI 07 PR ENSURE 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 ARE NOT RECUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) 01 ( ) 02 t ) 03 <br /> ( ) O1 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( 102 ( ) 03 <br /> ( 1 01 f ) 02 l ) 03 <br /> ( I Ol ( 1 02 f 1 03 <br /> f l <br /> 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 t ) 03 <br /> ( 1 01 l ) 02 ( ) 03 <br /> ( 7 01 ( ) 02 ( ) 03 <br /> ( I O1 ( 1 02 f 1 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 BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERS FICIN SZ N VRE1 PH W/AREA CODE <br /> FOR LOCAL AG NCY USE ONLY <br /> AOMINh'3 F;- NCY / ` / CITY CODE COUN7Y�ODE <br /> M <br /> CON,T4CT PER N PXO E W/ REA CODE <br /> DATE OF LAST//INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> /f Q d ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) Perno�e.® PAGE 2 <br />