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STATE ID NUMBER 00000053602002 <br /> CONTAINER CONSTRUCTION <br /> E. 4 ) 01 RUBBER LINED ( ) 02 ALKYD LINING [ 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING i ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: i ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE f ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORE© IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT RERUIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOFED <br /> ( 1 01 ( 1 02 t 1 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 { ) 02 ( 1 03 <br /> ( 1 O1 ( ) 02 ( 1 03 <br /> f ) Ol f ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( 1 01 ( ) 02 ( ] 03 <br /> f ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> f 1 01 ( ) 02 ( 1 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 /> PEPSCN FILING (SIGNATURE)4 PHONE W/AREA CODE <br /> mnv"& <br /> -- ©y- 544- 111 <br /> FOR LOCAL AGENCY USE ONLY <br /> DMZNISTZATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION JIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES ( S 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />