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r <br />CONTAINER CONSTRUCTION <br />STATE ID NUMBER 00000002150001 <br />E. ( ) 01 RUBBER LINE ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( H 04 PHENOLIC LINING f ) 05 GLASS LINING <br />I ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( D 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN" t ) 05 NONE <br />( ) 06 TAR OR ASPHALT t 1 09 OTHER <br />VI PIPING <br />A. ABOVEGROUND PIPING: ft 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (X) 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 BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( l 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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />)- 01 <br />( ) 02 <br />( ) 03 <br />t l 01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( D 03 <br />t ) Ol <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />O 03 <br />(') 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( l 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? ( l 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 LNG (SYGN REl RHONE W/AREA CODE <br />e <br />f�ll�(��a�m\►�:te a►i��la_"f �01r`0 �1 <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />CONTACT PERSON PHONE W/AREA CODE <br />DALE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATETRANSACTION DATE LOCAL PERMIT ID E <br />( ) 01 YES ( l 02 NO <br />HSC04-070165 (10/18/85) PAGE 2 <br />