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STATE ID NUMBER 00000054576001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPGXY LINING ( a 04,PHENOLIC LINING f ) 0'S GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER <br /> F. ( ) 01 POLYETHLENE WRAP ( -1 02 VINYL WRAPPING (` ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f } 05 NONE <br /> ( ) 06 TAR OR ASPHALT t } 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( l 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE'BOX(ES) ( ) 04 PRESSURE ( } 05 SUCTION t ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—"LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( J 06 UNKNOWN t ) 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL ( ) 02 STOCK INVENTORY ( a 04 VAPOR SNIFF WELLS c 1 05 SENSOR INSTRUMENT <br /> 06 GROUPED WATER -(1ONITORING WELLS c } 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL C-OMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REgUIREO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> D 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> t l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> C ) 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> E } 01- ( ) 02 ( ) 03 <br /> ( ) 02 ( ) 02 ( ) 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 /> PERSON FILI-NPHONE W/AREA CODE <br /> G (S G ATUR;E) <br /> i ?A <br /> FOR LOG L ACE USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMST APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( J 02 NO <br /> HSC04-070185 (10/18/8:5) PAGE 2 <br />