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STATE ID NUMBER 00000001864004 <br /> CONTAINER CONSTRUCTION <br /> E. l ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) Ol DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH GRAVITY <br /> (CHECK APPROPRIATE BOXf ES) ( ) 04 PRESSURE WW-�C"W ( 1 06 UNKNOWN ( ) N E <br /> VISI( LEAK DETECTION <br /> fry <br /> 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST (X) 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU C41CKED 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 /> ( ) <br /> al ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( l O1 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( 1 02 ( ) 03 <br /> ( ) Ol f 1 02 ( ) 03 <br /> l ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ! 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> CH'.CK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 FILL (SIGNATURE) PHONE W/AREA CODE p <br /> 4 <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMI NZ STR ATiNO AGENCY //,�,, II CITY CODE COUNTY CODE <br /> (✓ /dam G 7 <br /> CONTACT PEPSOIi / ^,� � PHONE W/AREA CODE <br /> DATE �OJF, IAS T\V/Z 5 ICJJT�(I//ON INCOMPLIANCEPERMIT APPROVAL DATE TWANSACTION DAT! LOCAL PERMIT ID L <br /> (2 �/ f ) <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />