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I <br /> T <br /> STATE IO NUMBER 00000008286001 <br /> ONTAINER CONSTRUCTION <br /> 1 RUBBER LINES} ( ) 02 ALKYD LINING [ ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 Ob GLASS LINING <br /> 1 07 UNLINED ( ) Q8 UNKtdOWN i ) 09 OTHER. j <br /> i <br /> } <br /> 01 POLYETHLENE WRAP i ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( <br /> { ) 06 TAR OR ASPHALT I ) 09 OTHER ) 05 NONE <br /> PIPING <br /> OVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 3 02 CONCRETE-LINED TRENCH i ) 03 GRAVITY <br /> HECK APPROPRIATE 80X(ES} i ) 04 PRESSURE ( } 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> rgn4� <br /> BOXES) ( ) 04 PRESSURE IX) 05 SUCTION I 1 06 UNKNOWN ( 1 07 NONE <br /> LEAK DETECTION <br /> 01 VISUAL W) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> 06 GROUND WATER MONITORING WELLS (x) 07 PRESSURE TEST PW 09 NONE ( ) 10 OTHER <br /> CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> YOU CHECK_D YES -O IV-w YOU ARE NOT RECJIRED TO COMPLETE THIS SECTION <br /> ENTLY PP!V:M'-SLY tZLETE CAS72 (IF KNOWN) <br /> D STOPED CHEMICAL (DO NOT USE COMMERCIAL NAME] <br /> 1 ( l 02 ( ) 03 <br /> 1 ( ) Q2 ( ) 03 <br /> 1 ( ) 02 ( ) 03 <br /> ( 1 02 ( ) 03 <br /> i <br /> ( } 02 ( ) 03 � <br /> QI f l 02 ( 1 03 <br /> 1 ( 1 02 ( } 03 <br /> 01 ( 1 02 ( ) 03 <br /> 1 E ) 02 ( } 03 <br /> 1 ( 1 02 ( f 03 - I <br /> K STATE SIIARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS _ <br />)NTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> IM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> PHONE W/AR A CODE <br /> OCAL AGENCY USE ONLY <br /> TR..TZNG •CEYCY <br /> CITY CODE COUNTY CCCE <br /> PERSON <br /> 7 "ONE W/AREA CODE <br /> D T INSPECTION IN COYIPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO X <br /> ( of YES r 02 NO <br /> 1 <br /> 370185 (10/18/85) <br /> PAGE 2 <br /> 1 � <br />