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STATE ID NUMBER 00000011758002 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( } 05 GLASS LINING <br /> ( 1 07 UNLINED (X) 08 UNKNOWN i ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( l 02 VINYL 'WRAPPING f ) 03 CATHODIC PROTECTION [ 1 04 UNKNOWN ( 1 05 NONE <br /> (X) 06 TAR OR ASPHALT ( 1 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH C ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE ( ) 05 SUCTION t ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN l ) 07 NONE <br /> VII LEAK DETECTION <br /> yX<01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> C 1 06 GROUND WATER MONITORING WELLS L)CY-07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ADE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPPED STOPED <br /> i t 01 ( 1 02 C 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( } 01 ( ) 02 t ) 03 <br /> C 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( l 02 C 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 t ) 02 C ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( ) 01 C 1 02 ( ) 03 <br /> ( ) 01 f ) 02 t 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 /> �PEPSON FILIN3 ( NATU?E) � <br /> PHONE W/ARE.A CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTVATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE JPERMIT APPROVAL DATE TRANSACTION DATE LCCAL PEEMIT ID # <br /> 4 1 01 YES C ) 02 NO <br /> HSC04-07C105 (10/18/85) PAGE 2 <br />