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CONTAINER CONSTRUCTION STATE ID NUMBER 00000004169005 <br /> E <br /> RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f 7 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION f ) 04 UNKNOWN f ) 05 NONE <br /> 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> [AABOVEGROUND PIPING: ( O1 DOUBLE-WALLED PIPE f 7 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) f 1 04 PRESSURE [ ) 05 SUCTION l ) 06 UNKNOWN ( 1 07 NONE <br /> UNDERGROUND PIPING: ( 7 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS 00-07 PRESSURE TEST f 1 09 NONE 01} 10 OTHER: S <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YIS TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVICUSLY DELETE CAS% (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ] 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 - ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 I ) 03 <br /> f 1 01 ( ) 02 ( l 03 <br /> [ ) O1 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> f l 01 f ) 02 ( l 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 f ) 03 <br /> ( 1 01 ( ) 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 BT COMPLETED UNDE"E,47ALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEPSO ONATURE) PHONE W/AREA DE <br /> -u - <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMI NISTRATI AGENCYIZ& CITY CODE COUNTY G00! <br /> CONTACT PCPSON <br /> PHqNE W/AREA CODE <br /> 90f� <br /> DATE OF LAST INSPECTION INCOMPLIANOC PERMIT APPROVAL DAT C TRANSACTION DAT! LOCAL PERMIT ZO % <br /> [ ) 01 YES ( ) OE NO <br /> MSC04-070185 (10/18/85) PAGE 2 <br />