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STATE ID NUMBER 00000065671002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING 1 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER( <br /> F. 1 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 (LONE <br /> ( ) 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) ( ) 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 BOXIEST ( ) 04 PRESSURE IX) 05 SUCTION 1 1 06 UNKNOWN l 1 07 NONE <br /> VII LEAK DETECTION <br /> I ) 01 VISUAL (X1 02 STOCK INVENTORY l 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND NATER MONITORING WELLS f ) 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 CASS (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( 1 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( 1 02 1 1 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> t ) el t 1 02 t ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 [ ) 02 t ) 03 <br /> [ )__01 ( <br /> 1 02 1 ) 03 <br /> ( ) O1 ( 102 ( ) 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES (X) 02 NO <br /> THIS FORM HAJWN4 COMPLETE E PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PER IN IGNA E) PHONE W/AREA CODE <br /> FOR LOC L AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/ARCA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID S <br /> ( ) 01 YES 1 ) 02 NO <br /> HSC04-070185 (05/05/86) PAGE 2 <br />