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• <br /> CONTAINER CONSTRUCTION <br /> STATE ID NUMBER 0000003493500 <br /> P <br /> O1 RUBBER LINEDXl 07 UNLINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING( ) 08 UNKNOWN ( l 09 OTHER: <br /> O1 POLYETHLENE WRAP ( ) 05 GLASS LINING <br /> ( 1 06 TAR OR ASPHALT ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN <br /> ( ) 09 OTHER: <br /> 05 NONE <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: <br /> (CHECK APPROPRIATE BOX ES) ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH <br /> ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN <br /> B. UNDERGROUND PIPING: ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) pl DOUBLE-WALLED PIPE ) 07 NONE <br /> ( ) 04 PRESSURE ( ) 02 CONCRETE-LINED TRENCH (NO 03 GRAVITY <br /> (SG:D 05 SUCTION ( ) 06 UNKNOWN t�() 07 NONE <br /> VII <br /> LEAK DETECTION <br /> SUAL <br /> ` ,1IGROUND(X) 02 STOCK W,ATER MONITORING"WE <br /> RY <br /> 06LLS ( ) 04 VAPOR SNIFF WELLS <br /> (X) 07 PRESSURE TEST ) 05 SENSOR INSTRUMENT <br /> ( ) 09 NONE ( l 10 OTHER: <br /> IF YOU CHECF:ED <br /> VIII CHEMICAL COMPOSITION OF <br /> YES TO IV-F MATERIALS STORED IN UNDERGROUND <br /> YOU ARE NOT P,EqUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE cAsu (IF <br /> KNOWN) CONTAINERS <br /> STCF.EQ STORED <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> f l 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> PHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE,PEP FIL NG (SI NATURE GE, IS TRUE AND CORRECT. <br /> PHONE W/ARE,A CODE <br />= R LOCAL AGENCY USE ONLY �� <br />;DMINISTR.ATING AGENCY <br /> / CITY CODE <br /> ONTACT PERSON COUNTY CODE <br /> 3 <br /> PHONE W/AREA CODE <br /> rE OF LAST INSPECTIONf? LI <br /> IN COMPLIANCE <br /> ( ) 01 YES ( ) 02 NO PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT Ip # <br /> H•070185 (10/18/85) 0 Joe- re pI pved <br /> PAGE 2 <br />