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1 <br /> STATE ID NUMBER 00000038894001 ' <br /> CONTAINER CONSTRUCTION <br /> E. ( )' 01 RUBBER LINED f ) 02 ALKYO LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING f -} 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION ( D 04 UNKNOWN ( 2 05 NONE <br /> (X) 06 TAR OR ASPHALT ( } 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING': f ) OI DOUBLE-WALLED PIPE { ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(EES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X)`04 PRESSURE ( l 05 SUCTION ( ) .06 UNKNOWN t ) 07 NONE <br /> VII LEAK DETECTION <br /> t ) 01 VISUAL (X) 02 STOCK INVENTORY ( D 04 VAPOR SNIFF WELLS t l 05 SENSOR INSTRUMENT <br /> ) 06 GROUND WATER MONITORING WELLS t } 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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t } 01 ( ) 02 ( ) 03 <br /> f l 01 ( } 02 ( ) 03 <br /> ( D 01 ( } 02 ( l 03 <br /> ( ) 01 t ) 02 ( ) 03 <br /> ( ) 01 ( D 02 ( ) 03 <br /> t l 01 t ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> E ) 01 ( ) 02 ( ) 03` <br /> 02 ( D 03 <br /> * CHECK 'STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAItJER LOCATED ON AN AGRICULTURAL FARM? t } 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 /> REP= IL ZGNATURE) PHONE W/AREA CODE <br /> V,,� <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN% TPA:TING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAt PERMIT ID: # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />