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0 <br /> STATE ID NUMBER 00000900723001 <br /> CONTAINER CONSTRUCTION <br /> E. f I 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING ( l 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> (X) 07 UNLINED t ) 08 UNKNOWN ( ) 09 OTHER= <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING 4 T 03 CATHODIC PROTECTION ( J 04 UNKNOWN t4eE3ff-m1"E <br /> X 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( l 01 DOUBLE-WALLED PIPE t J 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE--WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) (X) 04 PRESSURE ( 1 05 SUCTION C ) 06 UNKNOWN t l 07 NONE <br /> VII LEAK DETECTION <br /> ( 7 <br /> 01 VISUALf 0�e STOCK INVENTORY ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUNVWATER MONITORING WELLS C 1 07 PRESSURE TEST E ) 09 NONE ( ) 10 OTHER* <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY �PFVICUSLY DELETE CAS.- (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> 1 01 ( ) 02 ( ) 03 <br /> f l 01 ( ) 02 ( ) 03 <br /> ( ) Dl ( 1 02 ( ) 03 <br /> ( l 01 ( T 02 t ) 03 <br /> ( ) 01 ( J 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( l 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( ) 01 f l 02 ( l 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS Cq4,TAINER LOCATED ON AN AGRICULTURAL FAPrl? [ ] 01 YES (X) 02 NO <br /> THIS F M HAS B EN C PLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, 15 TRUE AND CORRECT. <br /> PEPSON F I ' IGN, RE PHONE W/AREA CODE 2--? {ray <br /> //✓ - <br /> FOR LOC L AGENCY USE ONLY <br /> ADMIN TP NG AGG�ENNCY - CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> TRANSACTION BATE LOCAL PERMIT ID # <br /> DATE OF LAST INSPECTION IN COMPLIANCE tP�ZT APPROVAL DATE <br /> 1.-;2-- 4F00 C1 YES i l 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />