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STATE IO NUMBER 00000024872003 <br /> ANER CONSTRUCTION <br /> RUBBER LINED ( ),02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) OS GLASS LINING <br /> .) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER( <br /> 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN 1 1 05 NONE <br /> f ) 06 TAR OR ASPHALT ( ) 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 (X) 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) OS SUCTION ( ) 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> l ) <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( ] 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS 1A.07 PRESSURE TEST ( ) 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# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> 1 LOl ( 1 02 ( ) 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> l 1 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 f 1 02 ( ) 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 /> HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> 6°ERSON FILING (SID R ) PMONE W/AREA CODE ll <br /> Y <br /> 'FOR LOCAL AG NCY USE ONLY <br /> ADMI. ISTRA I. ACE NCV CITY CODE COUNTY CODE <br /> 1d 3 <br /> DONT.CT PERSON 0 PHONEpW/AREA CODE <br /> j J g <br /> 7_157- <br /> 3A- OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> i ( ) Ol YES�� �(nO 00022 NO <br /> 3C04-070185 (10/18/85) " " ' ) ' PAGE 2 <br /> r <br />