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STATE ID NUMBER 00000013932007 <br />CONTAINER CONSTRUCTION <br />( ] 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER= <br />( 1 <br />01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br />f ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />4. ABOVEGROUND PIPING- ( ) 01 DOUBLE -WALLED PIPE f ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE [ 1 05 SUCTION ( ) 06 UNKNOWN 01 1 07 NONE <br />3. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL QO 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />f ) 06 GROUND WATER MONITORING WELLS 07 PRESSURE TEST W -r'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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />(aq O1 <br />( ) 02 <br />i <br />( ) 03me�of- <br />f 1 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />( ) O1 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />f 1 01 <br />( 1 02 <br />( 1 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />[ ) Ol <br />( ) 02 <br />l ) 03 <br />( l O1 <br />f ) 02 <br />( ) 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, <br />I'S TRUE AND CORRECT. <br />PERSON FAIN (SIONAT ) PHONE /AREA COD,( <br />FOR LOCAL G CY USE ONLY <br />ADMINISTPATIAGENCY CITY CODE COUNTY CODE <br />CONTACT PERSON PHONE W/AREA CODE <br />DATE CF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID C <br />( ) 01 YES l 1 02 NO <br />4-070185 (10/18/85) <br />PAGE 2 <br />