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STATE ID NUMBER 00000062408002 <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04 PHENOLIC LINING ( } 0'5 GLASS LINING <br />(X) 07 UULINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHL.ENE WRAP t 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION C ) 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT ( 3 09>OT14ER <br />VI PIP.INC <br />A. ABOVEGRpUNO PIPING: E ) 01 DOUBLE—WALLED PIPE(, 3 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOXtES) ( d 04 PRESSURE ( ) 05 SUCTION t D 06 UNKNOWN ;( ) 07 NONE <br />B. UNDERGROUND PIPING: t } 01 DOUBLE—WALLED PIPE ( l 02 CONCRETE -LINED TRENCH 03 GRAVITY <br />tGHECK APPROPRIATE BOX(ES) t D 04 PRESSURE t 105 SUCTION ( ) 06 UNKNOWN { 1 07 NONE <br />VII LEAK DETECTION, <br />t ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS { ) 05 SENSOR INSTRUMENT <br />r f ) 06 GROUND WATER MONITORING WELLS t D 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br />i <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDER=GROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STOPED <br />PREVIOUSLY <br />STORED <br />DELETE CAS:# CIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />f l 01 <br />( )` 02 <br />t) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 !! EE ff tt <br />t } 01 <br />( ) 02 <br />( 1 03 <br />( ?01 <br />E )02 <br />f )03 <br />( ) 01 <br />E } 02 <br />( ) 03 <br />{ } 01 <br />( 1 '02 <br />( ) 03 <br />( ) 01 <br />( )"02 <br />( ) 03 <br />( l 01 <br />t l 02 <br />( 1 03 <br />{ ) 01 <br />( ) 02 <br />( ) 03 <br />f ,) 01 <br />f ) 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 19Y KNOWLEDGEt IS TRUE AND CORRECT. <br />PERSON PILI SIC,NATURE ' PHONE WIAREA CODE <br />A71 D) <br />ADMINISTRATING ASENCY CITY CODE COUNTY CODE <br />CONTACT PERSON PHONE W/AREA CODE <br />LOCAL PERMIT ID <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br />( ) 01 YES ( ) 02 N0 <br />HSC04-070185 ('10/18/853 <br />PAGE 2 <br />