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STATE ID NUMBER 00000051098003 <br />CONTAINER CONSTRUCTION <br />E. 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING 04 PHENOLIC LINING t d 05 GLASS LINING <br />) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br />F. (X) 01 POLYETHLENE WRAP E l 02 VINYL WRAPPING 03 CATHODIC PROTECTION 04 UNKNOWN 05 NONE <br />( ) 06 TAR OR ASPHALT 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: 01 DOUBLE-WALLEO PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) t ) 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) (>d 04 PRESSURE 44cT os SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />01 VISUAL (X) 02 STOCK INVENTORY f D 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT <br />) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( 09 NONE L)cT 10 OTHER: tJv"e Ve�-'oeo <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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <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 />ol <br />02 <br />f l 03 <br />fl 01 <br />02 <br />03 <br />OI <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 ER 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 FALIG (S!,dNATU PHONE W/AREA CODE <br />C4- km 1 -.00 <br />C/ ELU!" lcgc)2 <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />CONTACT PERSON PHONE W/AREA CODE <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # <br />I ( ) 01 YES 02 NO I I <br />HSC04-070185 (10/18/85) PAGE 2 <br />