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STATE ID NUMBER 00000038894003 <br /> CONTAINER CONSTRUCTION <br /> aE. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING f 104 PHENOLIC LINING t ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN t _D 09 OTHER <br /> F. t D 01 POLYETHLENE WRAP ( 102 VINYL 'WRAPPING ( D 03 CATHODIC PROTECTION ( J 04 UNKNOWN ( D 05 NONE <br /> (X) 06 TAR OR ASPHALT ( i 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE—WALLED PIPE f ) 02 CONCRETE—LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( D 05 SUCTION ( ) 06 UNKNOWN ( J 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE t ) 05 SUCTION t D 06 UNKNOWN t ) 07 NONE <br /> i <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY f D 04 VAPOR SNIFF WELLS' ( ) 05 SENSOR INSTRUMENT <br /> It ) 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 P,EgUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> E ) 01 ( 1 02 ( ) 03 <br /> t ) 01 t ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t J 01 ( D 02 ( ) 03 <br /> { ) 01 t ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( D 01 ( l 02 ( ) 03 <br /> f 01 t ) 02 ( ) 03 <br /> t ) 0,1 ( ) 02 ( ) 03 <br /> ( `) 01 ( ) 02° ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />' TIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l 01 YES (X) 02 NO <br />`IFORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> }' PERSON ZLI ( ATURE) PHONE W/AREA CODE <br /> rOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE, COUNTY CODE <br /> L2�� <br /> 57 <br /> CCNTACT ERSON PHO E W/ -EA CODE <br /> a <br /> DATE OF LAST INSPECTIOrINCOMPLIANCE( PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> YES ) 02 NO <br /> HSCO'f-070185 (10/18/85) PAGE 2 <br /> c <br />