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y STATE ID NUMBER 00000013166002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING t ) 04 PHENOLIC LINING [ l 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: { 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNCERGROUND PIPING: ( ).j1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK AFFROFRIATE BOX(ES) (jq 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GR MONITORING WELLS ( l 07 PRESSURE TEST (X) 09 NONE f ) 10 OTHER' <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED 'YES TO :V-F YOU .ARE NOT REQUFRED TO COMPLETE THIS SECTION <br /> CUPREN7LY PPE'V-O'USLI" DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE CCMMERCIAL NAME) <br /> STC;EO STCPEC <br /> ( 1 01 ( ) 02 t 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 f ) 02 i l 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 O1 ( ) 02 ( 1 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 f ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( l 01 i ) 02 1 1 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 /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FF NG !SIGN.4TUR ? �y PHONE W/AREA CODE <br /> Ufa <br /> FOR LOCAL GENCY USE ONLY <br /> ADMINISTPAIING AGENCY CITY CODE COUNTY CCDE <br /> S Al ud AkV!;'I L()CA . f5 <br /> CONTACT ?EPSON PHONE W/APEA CODE <br /> X>f UTS 0 <br /> DATE OF LAST -NS"ECT2ON IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 1 ) 01 YES C ) 02 NO <br /> HSC04-070185 (10/18/85) r <br />