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STATE ID NUMBER 00000000726003 <br />CONTAINER CONSTRUCTION <br />( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN f ) 09 OTHER: <br />( ) <br />01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />(. ABOVEGROU140 PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />i. UNDERGROUND PIPING= ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( 1 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ( ) 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 APE NOT PEGUIPED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( 1 03 <br />( ) 01 <br />( ) -02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />f 103 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />f ) 02 <br />( l 03 <br />f l 01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IIS CONTAIN LOCATED ON AN AGRICULTURAL FARM? ( l 01 YES (X) 02 NO <br />14IS FORM JAS)BEEN COMPLET UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSON FI I 3 (G4TUP. ^ Pjt'ONE WiAREA CODE <br />1,/ <br />FOR L <br />AL NCY USE ONLY <br />ADMIN kTPATING <br />AGENCY I <br />CITY CODE <br />COUNTY CODE <br />CONTACT <br />PERSON D <br />COD <br />PHO�'W�'� E <br />�rA,r� u i <br />o� 3 <br />r- <br />3 3 t -3 <br />DATE OF <br />LAST INSPECTION <br />IN COMPLIANCE <br />PERMIT APPROVAL <br />DATE <br />TRANSACTION DATE <br />LOCAL PERMIT ID # <br />( ) 01 YES ( <br />) 02 NO <br />HSC04-070185 (10/18/85) PAGE 2 <br />