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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> F( 3 <br /> 1 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ) 07 UNLINED W 08 UNKNOWN ( ) 09 OTHER: <br /> POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION 01'04 UNKNOWN 1 ) 05 NONE <br /> 06 TAR OR ASPHALT ( ] 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION f 1 06 UNKNOWN ( 1 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 ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL Oq 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT I <br /> ( ) 06 GROUND WATER MONITORING WELLS 00 07 PRESSURE TEST ( ) 09 NONE W 10 OTHER: (...()1f- +-e v- .ik�ec`�0►�- <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 CASU (IF KNOWN) <br /> STORED STORED CHEMICAL IDD NOT USE COMMERCIAL NAME) <br /> ( ) 01 ( ) 02 1 ) 03 1_1 I <br /> ( ) Ol f 102 ( ] 03 <br /> f l Ol f ) 02 ( ) 03 <br /> ( 1 01 l ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) Ol ( ) 02 f ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 f ) 03 <br /> IS CO!(TAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 04'02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEPSO4 FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY l CITY CODE COUNTY CODE <br /> oa Lo s 1 3 <br /> CONTVT PERSON PHONE W/AREA CODE <br /> Lk i&f <br /> DATE OF LAS INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID D <br /> ( ) 01 YES f ) 02 NO <br /> ASC04-070185 PAGE 2 <br />