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• • STATE ID NUMBER 00000028041001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f ) 04 PHENOLIC LINING f l 05 GLASS LINING <br /> t ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01. POLYETHLENE WRAP ( ] 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 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 f ) 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE - <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) OS SUCTION f 1 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL '�02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> f ) 06 GROUN6 WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE ( ) 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 (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 ) 01 ( ) 02 f ) 03 <br /> ( ) 01 ( ) 02 (. ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 7 01 ( ) 02 ( ) 03 <br /> f J Ol ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> 1 ) ,01 f ) 02 ( 1 03 <br /> l 01 ( 102 ( ) 03 <br /> f Y 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 /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PE R�SON FI I G (S NATURE)- PHONE 1/AREA CODE <br /> FOR LOCAL A NCY USE ONLY <br /> ADMINIS�A7jI N0�AGE NCY S CITY CODE COUNTY CODE <br /> r�riv ulAl �icAt 6c if <br /> CONTACT PER <br /> �' Z 1//V <br /> ,V^,!d ! <br /> PHONE qCODE 3 - <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION 0, LOCAL PERMIT ID # <br /> 01 YES < ) 02 NO <br /> RSC04-070185 (10/18/85) PAGE 2 <br />