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0 <br />STATE ID NUMBER 00000014862002 <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br />(X) 07 UNLINED ( )'08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN t ) 05 NONE <br />(X) 06 TAR OR ASPHALT { ) 09 OTHER: <br />PIPING <br />A. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOXES-) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOXES) (X) 04 PRESSURE ( ) 0`5 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />01 VISUAL (X) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER -MONITORING WELLS ( ) 07 PRESSURE TEST t D 09 NONE f ) 10 OTHER: <br />VIII CHEMICAL COMPO<SITIO:N OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO-IV.F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />( D 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />t ) 03' <br />01 <br />( ) 02 <br />( ) 83 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR 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 />E ON FIL SYGNATURE) PHONE W/AREA CODE <br />4 <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />CONT&CT PERSON PHO E W/AREA GORE <br />q77 t <br />DATE OF LAST INSPECTION JIN: COMPLIANCE JPERMIT APPROVAL DATE TRANSACTION DATE FOAL PERMIT IO # <br />( ) 01 YES ( ) 02 NO 1. <br />HSC04-070185 (10/18/85) <br />0 <br />PAGE 2 <br />