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STATE ID NUMBER 00000008404004 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED i l 02 ALKYD LINING ( l 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ] 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( l 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH i ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f l 04 PRESSURE ( ) 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: i l 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPRCPRIATE BOX(ES) ( 1 04 PRESSURE ( 1 05 SUCTION [ 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS t ) 07 PRESSURE TEST ( 1 09 NONE f ) 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 KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STCPED _ <br /> (X) 01 ( l 02 ( l 03 171618111-15121-191 NOT ON LIST <br /> ( ) al f l 02 ( ] 03 <br /> ( 1 <br /> 01 f 1 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 t ) 02 f ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL. AGENCY USE ONLY <br /> AOMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION @RTE LOCAL PERMIT ID # <br /> ) 01 YES f } 02 ND <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> 0 <br />