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STATE ID NUMBER 00000031536001 <br /> CONTAINER CONSTRUCTION <br /> E. [ 1 01 RUBBER LINED ( f 02 ALKYD LINING ( 1 03 EPDXY LINING i ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP i ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION f 1 04 UNKNOWN Q< 05 NONE <br /> ( ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f 1 01 DOUBLE—WALLED PIPE f 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN WT 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXtES) ( 1 04 PRESSURE (X) 05 SUCTION ( D 06 UNKNOWN ( 1 07 NONE <br /> ___ <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS t 1 07 PRESSURE TEST t 1 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED 'eES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPRENTLY PREVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOZED STOPED <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 f 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> t ) 01 ( 1 02 t 1 03 <br /> ( 7 <br /> 01 ( 1 02 ( ) 03 <br /> { ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 7 02 C 1 03 <br /> ( 1 01 [ 1 02 ( 1 03 <br /> ( J 01 ( 1 02 4 1 03 <br /> ( ) 01 ( 7 02 i 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? i ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANOr TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> PEPSON FILING GNAT P PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSCy PHONE W/AREA CODE <br /> DATE OF LAST '-NSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ..� � ( ) 01 YES ( ? 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> i � <br />