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0 <br /> STATE ID NUMBER 0000001£304004 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING i 1 03 EPDXY LINING E ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED E ) 08 UNKNOWN ( ) 09 OTHER <br /> F. E ) 01 POLYETHLENE WRAP i ) 02 VINYL WRAPPING [ ) 03 CATHODIC PROTECTION i 1 04 UNKNOWN i ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING= E ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: [ 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f 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 YCU ARE N07 REG'JIRED TO COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CAS# (IF YNCWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STCPED <br /> ( 1 01 ( ) 02 1 ) 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> E ) 01 ( ) 02 ( 1 03 <br /> € 1 01 E ) 02 ( ) 03 <br /> [ ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 € 1 03 <br /> [ ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> E ) <br /> 01 t 1 02 ( ) 03 { <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f 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 €SIGNATUR ,�y� PHONE W:AREA CODE <br /> l(jJ r^f^(�J�} <br /> FOR 'LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITYJOE COUNTY CODE <br /> CONTACT PERSON PHONE W/AR A CODE <br /> a- 33q-~ 335 DL-- <br /> DATE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DALE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) Ol YES ( } 02 NC <br /> HSC04-070135 (10/18/351 PAGE 2 <br />