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STATE IO NUMBER 00000063414002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED C l 08 UNKNOWN ( l 09 OTHER: <br /> F. ( l 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING C ] 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> i l 06 TAR OR ASPHALT C ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) C 1 04 PRESSURE ( ) 05 SUCTION C 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING= ( 1 01 DOUBLE-WALLED PIPE t 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) QQ 04 PRESSURE ekr 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( l 01 VISUAL (X) 02 STOCK INVENTORY C ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR IN-STRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS i ) 07 PRESSURE TEST ( ) 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 REgUIRED TO COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (OO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( l 01 ( ) 02 ( r 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> 1 l 01 i 1 02 ( l 03 <br /> i ) 01 ( 1 02 C ) 03 <br /> ( ) <br /> 01 ( ) 02 c ) 03 <br /> C l <br /> 01 ( ) 02 [ ) 03 <br /> [ 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 C ) 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 COMPLETED UNDER Tr PEN TY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> EPSON eX SI PHON WfAKA CODEvv <br /> FOR LAGENCY USE ONLY <br /> AON:NISTRATIN^a GENCY CITY CODE COUNTY CODE <br /> o <br /> t <br /> CONTACT <br /> EP.SON FHO WfAREA CODE <br /> DATE OF LAST INSPECTION IN OOhiPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18185) PAGE 2 <br />