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STATE ID NUMBER 00000000726001 <br />CONTAINER CONSTRUCTION <br />( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( l 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT ( l 09 OTHER: <br />VI PIPING <br />ABOVEGROUND PIPING: <br />( ) 01 DOUBLE -WALLED <br />PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />( ) 04 PRESSURE ( <br />) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 <br />NONE <br />UNDERGROUND PIPING: ( <br />) 01 DOUBLE -WALLED <br />PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK. APPROPRIATE BOX(ES) <br />(X) 04 PRESSURE ( <br />) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 <br />NONE <br />VII LEAK DETECTION <br />( l 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST ( ) 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 />STOPED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) O1 <br />( ) 02 <br />( l 03 <br />( ) 01 <br />( l 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />f ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( ) 02 NO <br />THIS FORW HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />HSC04-070185 (10/18/85) PAGE 2 <br />FEFSON IL' U(E) <br />)PHONE <br />W/.AREA <br />CODE <br />F LOCAL AGENCY <br />USE ONLY <br />INISTP.A7aG AGENCY <br />rC <br />CITY CODE <br />COUNTY CODE <br />V'GJ <br />L V+ L J <br />-3 <br />CONTACT RSO <br />PHONE <br />/AREA <br />D <br />( n <br />a i- 3 3 3 <br />DATE OF LAST INSPECTION <br />IN COMPLIANCE <br />PERMIT APPROVAL DATE <br />TRANSACTION DATE <br />LOCAL PERMIT ID # <br />( ) 01 YES ( 1 02 NO <br />HSC04-070185 (10/18/85) PAGE 2 <br />