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STATE I0 NUMBER 00000028041003 <br />v( ) <br /> R CONSTRUCTION <br /> LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> INED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> IF- ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X)04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE 80X(ES) ( l 04 PRESSURE (X1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST (X) 09 NONE ( 1 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. STOREO <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 O 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( 1 Ol f ) 02 f ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( l <br /> 01 ( ) 02 f ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( ) 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 FI L (SI NATUREQ PHONE W/AREA CODE <br /> FOR LOCAL A aNCY USE ONLY <br /> ADMIN ISJ,RAT` G AGENCY CITY CODE .COUNTY CODE <br /> _.>/lL" U/Ry LOCfYG fl-C7/ <br /> CONTACT PERSON Y1 '^ PHONE W/AREA CODE <br /> DATE CF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) <br /> 01 YES ( 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />