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STATE ID NUMBER 00000061953003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING f ) 03 EPDXY LINING f l 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: <br /> F. f ] O1 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 103 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE QO 05 SUCTION ( 1 06 UNKNOWN (. l 07 NONE <br /> VII LEAK DETECTION <br /> '1 ) O1 YISUAL (X) 02 STOCK INVENTORY [ ) 04 VAPOR SNIFF WELLS ( 105 SENSOR INSTRUMENT <br /> ( ) 06 SUAL ) WATER MONITORING WELLS (�1_0.7_P$ESSSRI_TE3WE l 109 NONE ( ) 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHF.CK.EO YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ' C ) 03 <br /> ( ) 01 t ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> al ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( 1 0l ( ) 02 ( 103 <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 /> PERSON FILING (SIGNA E) PHONE W/AREA C , <br /> Q <br /> FOR LOCAL AGEqCY USE ONLY <br /> ADMINIST TI NO A^ENCY ,� f� 1 CITY CODE COVNTY CODE <br /> iv <br /> CO NTACHONE� /VLl j P1�S L1R EA CODE (Z/ <br /> orp <br /> DATE F LAS INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAs P[RMIT ID k <br /> — Z� ( ) 01 YEST3 J 02 NO <br /> HSC04-070185 (10/18/851 PAGE 2 <br />