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STATE ID NUMBER 00000002918002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01E LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) INED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 O1HLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> (X) OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 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: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) AWI)' 7lPJSERt (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE IX) 10 OTHER: SMELL <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 (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) 01 ( ) 02 ( ) 03 HEATER OIL OR HEATER FUEL <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ] 02 ( ) 03 <br /> ( ) 01 ( ) 02 f 1 03 <br /> [ ) 01 f ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 f 7 02 ( ) 03 <br /> ( ) Oi ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 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? ( ) 01 YES (X) 02 NO <br /> TSOPE <br /> ORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE) IS TRUE AND CORRECT. <br /> FILING (SI AT E1 PHONE W/AREA CODE <br /> Fd LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> Se'llyjWAdYA1W L.oaot AkAt-IJas <br /> CONTACT PERSON PHONE W/AREA CODE <br /> 1211,22FLI, fair/yAk A -7 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> -Z--w - ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br />