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Sw <br /> STATE ID NUMBER 00000024871003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) O1 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( l 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ] 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING• ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION f ) 06 UNKNOWN PC 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS UQ 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 KNOWNI CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED JJ <br /> (X) 01 ( ) 02 ( ) 03 N9'C'OM�Ii'CT Wi lJJ /"(p5 c 0 &( Llo Z-owD'aL ra- <br /> ( ) O1 ( ) 02 ( ) 03 <br /> l ) 01 ( 1 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol f l 02 ( ) 03 <br /> ( 101 ( ) 02 ( ) 03 <br /> ( ) <br /> 0 <br /> 1 ( ) 02 ( ) 03 <br /> O1 ( ) 02 ( ) 03 <br /> i <br /> ( ) Ol f ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( 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 NATU E) I PHONE W/AREA CODE <br /> FOR LOC AGENCY USE ONLY <br /> A7. -NISTRATING AGENCY ` CITY CODE COUNTY CODE <br /> 3 <br /> CONTACT PERSO PHONE W/ARCA CODE <br /> FZ-Yi� <br /> �C&TE OF AST INSPECTION IN COMPLIANCC PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> Lb ) 01 YES p(1 y)NO2 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />