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STATE ID NUMBER 00000004373001 <br /> CONTAINER CONSTRUCTION <br /> E) OBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04 PHENOLIC LINING ( ) 05 GLASS LINING UNLINED (X) 08 UNKNOWN [ 1 09 OTHER: <br /> LYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> TAR OR ASPHALT I ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE i ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( J 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ) 04 PRESSURE --MM-05 SUCTION [ 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETE T <br /> (X) 01 VISUAL- C STOCK INVENTORY C ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS C ) 07 PRESSURE TEST ( ) 09 NONE l 1 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 KNCWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STCPED STOPED <br /> ( ) <br /> 01 ( ) 02 [ ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t l 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> al ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN CCMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, 15 TRUE AND CORRECT. <br /> PHONE WJAREA CODE <br /> w <br /> FOR LOCAL AGEN Y USE ONLY <br /> ADMINSTPATING AGENCY CITY CODE COUNTY CODE <br /> .-'w AWL,-, <br /> f- <br /> CCNTAC PERSON PHONE WJ REA CODE <br /> C �Q <br /> DATE OF LAST INSPECTION IN CCMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 )ES ( ) 02 NO <br /> HSC04-0701$5 (10/18/85) PAGE 2 <br /> �' r1 <br />