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! <br /> STATE ID NUMBER 00090014594005 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING t ) 04 PHENOLIC LINING € l 05 GLASS LINING <br /> k07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( } 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br /> X06 TAR OR ASPHALT f l 09 OTHER: <br /> �.1 <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXCES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGRCUND PIPING: ( O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE ( l 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> t } 01 VISUAL (X) 02 STOCK INVENTORY [ 1 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (X} 07 PRESSURE TEST ( ) 09 NONE ( } 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHEC!:_ .ES TC IV-F YOU APE NOT RECUIP.ED TO COMPLETE THIS SECTION <br /> CUPPENTLY PPE`-'IC'JSLY DELETE CASY. (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STOPED S70PEO <br /> ( ) 01 ( ) 02 C ) 03 <br /> ( 1 01 f l 02 t 1 03 <br /> ( l 01 f ) 02 f ) 03 <br /> ( } 01 ( } 02 ( 7 D3 <br /> € ) 01 ( l 02 ( ) 03 <br /> f ) 01 ( 1 02 f ) 03 <br /> O01 C102 ( 103 1 IIIIIIIII <br /> t } 01 ( 1 02 ( } 03 <br /> ( ) 01 ( ) 02 t ) 03 <br /> ( ) 01 ( 1 02 t ) 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 FILING (")GNAT -1 / PHONE W/AREA CCDE <br /> GG <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> ° �� <br /> DATE OF LAST I SPECTICN IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID U <br /> 1 )_ <br /> . 41` 4 3 01 YES ( ) 02 NO <br /> HSC04-0-70185 (10/18/85) PAGE 2 <br />