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CONTAINER CONSTRUCTION STATE ID NUMBER 00000063909002 <br /> FF ( <br /> 1 01 RUBBER LINED ( ) 02 ALKYD LINING i ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) OS GLASS LINING <br /> ( ) 07 UNLINED (X1 08 UNKNOWN ( ) 04 OTHER: <br /> Po <br /> 0.1 06 LYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 43 CATHODIC PR'OTECTIQN (X) 04 UNKNOWN ( ) 05 (:(7()E <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ) <br /> SUCTION W) 06 UNKNOWN F ] 07 NONE <br /> VII LEAK DETECTION <br /> =1 ) <br /> SUALIL NVENTnPY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENTGROUND WATER MONITORING WELLS ) 07 PRESSURE TEST f*1 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT RE4UIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVICUSLY DELETE CASK (IF KNOWN) <br /> STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> E ) 01 ( ) 02 ( l 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( l 01 ( 1 02 ( ) 03 `_— <br /> ( 1 01 i ) 02 ( ) 03 1 11 <br /> ( ) 01 [ 3 02 ( 1 03 <br /> f ) <br /> 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 -- <br /> 1 01 ( ) 02 € ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? i l 01 YES (X) 02 NO <br />'HIS - —�— �-- <br /> FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSONILING ( GNATURE) <br /> PHONE W/AREA CODE <br />=OR LOCAL AGENCY USE ONLY <br /> 4DM ISTRA�G AGENCY <br /> `7 ✓dQtli /�(�(��/ /�t�/ i/�fhe CITY CODE <br /> T �.•!/ �/ COUNTY (;ODE <br />:ONTACT PEPSO <br /> . Gr�I Tr PHONE W/ PEA CODE <br /> ��G,V gig- �ar� <br />:,TE OF LAST/I Sp/EGTION IN COMPLIANCE PEPMIT APPROVAL DATE TRANSACTION DATE <br /> //'4�/ iv ( ) 01 YES ( ) 02 NO LOCAL PERMIT 20 K <br /> C04-070185 (lo/18/85) <br /> PAGE 2 <br /> /�Pnr't� pn <br />