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STATE ID NUMBER 00000017798011 <br /> CONTAINER CONSTRUCTION <br /> E. ( )(O� RUBBER LINED(X1 OB UNKNOWN LINING <br /> 09 OTHER3 EPDXY LINING ( ] 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> UNL <br /> NED <br /> F. ( ) O1 POLYETHLENE WRAP [ 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER- <br /> VI PIPING <br /> A. ABOVEGROUPIPING' <br /> BOXIEST l ( 0104DPRESSURELED PIPE 02) 05 SUCTION CONCRETE-LINED( ) 06UNKNOWNTRO3 GRAVITY <br /> 07(NONE <br /> B (CHECKRAPPROPRIATEPIPING: <br /> BOX(ES) ( l 0104DPRESSURELEO 1105 SUCTION CONCRETE-LINED <br /> UNKNOWNTREN'H07 NON <br /> VII <br /> GRAVITY <br /> E <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 105 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS [ 1 07 PRESSURE TEST (X) 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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 1 1 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 f 1 02 ( ) 03 <br /> ( 7 01 ( ) 02 ( ) 03 <br /> ( ) 01 f 1 02 ( ) 03 <br /> l 1 01 ( 1 02 ( 1 03 <br /> ( ) <br /> 01 ( ) OE ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 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 /> PEPSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> 66-600o Eur� <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMZNIS TR ATIN3 AGENCY CITY CODE COUNTY CODE <br /> T7 I <br /> CONTACT ERSON PHONE W/AREA CODE 7 <br /> :DATE OF LAST INSPECTION INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) Ol YES f 1 02 NO <br /> HSC04-C70185 (10/18/85) PAGE 2 <br />