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STATE ID NUMBER 00000023075001 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING f 105 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( 7 03 CATHODIC PROTECTION 1X1 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> E <br /> OVEGROUND PIPING: ( 7 Ol DOUBLE-WALLED PIPE f l 02 CONCRETE-LINED TRENCH f 7 03 GRAVITY <br /> HECK APPROPRIATE BOXES) ( ) 04 PRESSURE 1 ) 05 SUCTION ( ) 06 UNKNOWN ^ 07 NONE <br /> DERGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> HECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUALAAI 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND-7A-TER MONITORING WELLS t ( ^? PRESSI-9 TFST `�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 CAS# (IP KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> ( ! O1 ( ) 02 O 03 <br /> f ) O1 f ) 02 ( ) 03 <br /> ( 1 Ol ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 Fl/L6 (S- NATO ) PHONE W/AREA CODE <br /> ao17 <br /> � <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN.� ATING AGENCY STP. CITY CODE COUNTY CODE <br /> '� 9 <br /> CONTACT PEWNPH NE AREA CODE <br /> 11 <br /> man Ile ��r /r1, /r7< /14m 2o����z- X170 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES f ) 02 NO <br /> HSC04-070185 110/18/85) PAGE 2 <br /> **awl <br />