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STATE ID NUMBER 00000011282001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION m 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ] 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(E5) ( ) 04 PRESSURE ( l 05 SUCTION ( 1 06 UNKNOWN ( $f 07 NONE <br /> B. UNDERGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION [ l 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> 'T0106VISUAL <br /> GROUND =ER MONITORINGINVENTORY <br /> WELLS ( 1 007VPRESSURESNIFF <br /> TESTWELLS l(09 NONE05 SENSOR 10 OINSTRUMENT <br /> HER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT PECUIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( ) <br /> 01 l ) 02 f ) 03 <br /> f ) Ol ( ) 02 f ) 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ] 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( l 03 <br /> f l <br /> 01 f l 02 f l 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 t ) 03 <br /> (� CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINERLOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES EX) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> RERS FILING (SIGNATURE PHONE W/AREA CODE <br /> o✓/ <br /> 69 <br /> �O !/ <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTP TING AGENCY CITY CODE COUNTY CODE <br /> fjdL <br /> CONTACT PEPSO PHONE W/AREA CODE <br /> e on — - Z <br /> DATE OF LAST INSPECTION IN COttPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> `/ ( ) <br /> HSC04-070185 (10/18/85) /V/v� � PAGE 2 <br />