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air <br />STATE ID NUMBER 00000057528001 <br />CONTAINER CONSTRUCTION <br />E. t ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( D 03 EPDXY LINING t ) 04 PHENOLIC LINING t } 05 GLASS LINING <br />( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING t } 03 CATHODIC PROTECTION ( } 04 UNKNOWN ( } 05 NONE <br />(X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: t ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f ) 05 SUCTION { ) 06 UNKNOWN 't ) 07 NONE <br />B. UNDERGROUND PIPING: (_) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) t d 04 PRESSURE ( 05 SUCTION NKK 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />t ) 01 VISUAL ( ) 02 STOCK INVENTORY t D 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING; WELLS t ) 07 PRESSURE TEST (X) 09 NONE t } 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 />CU'RR'ENTLY <br />STORED <br />PREVIC)USLY <br />STORES <br />DELETE CAS# (IF KNOWN) CHEMICAL (Df NOT USE COMMERCIAL NAME) <br />i <br />I t ) O1 <br />t ) 02 <br />( ) 03 <br />( 3 01 <br />( ) 02 <br />( ) 03 I ( (1 [ I ! <br />( )- OI <br />( ) 02 <br />( ) 03_ <br />( )' 01 <br />t I O2 <br />( ) 03 <br />( )1 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( l 02 <br />( ) 03 <br />( )'01 <br />( ) 02 <br />t ) 03 <br />( ) 01 <br />( d 02 <br />( ) 03 <br />01 <br />t 102 <br />( ) 03 <br />( ) 01 <br />( i-02 <br />( ) 03 <br />BOARD�klt,K STATE CHEMICAL CODEFOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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 />PERSON F I 0 N& E) PHONE WfAR-EA COj)E� ® / J�/ <br />_ w -e A r,® <br />FOR LOCAL <br />HSC04-070185 (10/18/85) <br />11 <br />