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STATE ID NUMBER 00000031628001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED i ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING t } 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( 3 04 UNKNOWN (x 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING- ( ) 01 DOUBLE-WALLED PIPE ( 3 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN >e 07 NONE <br /> B. UNDERGROUND PIPING= ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECE!D YES TO IV-F YOU ARE NOT REgJ:PEO TO COMPLETE THIS SECTION <br /> CUPPENTLY PPEVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> S-OPED STOPED <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> i 1 01 f ) 02 ( 1 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> f ) 01 i ) 02 ( ) 03 <br /> ( l 01 ( 1 02 ( ) 03 <br /> ( ) 01 t ) 02 ( ) 03 <br /> ( 1 <br /> 01 t ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 t 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X1 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 /> PEP.SON FILINCa,( ZGNAT A f `� PHONE W CODE <br /> �C�//tom i c <br /> FOR LOCAL LOCAL AGENCY USE ONLY <br /> _[ADMINISTRATING AGENZ1 CITY CODE COUNTY CODE <br /> CONTACT PEFSON PHONE W/AREA CODE <br /> DATE CF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID <br /> k)— 1 181 ( 1 01 YES 6 D 02 NO <br /> HSC04-070185 (110/18/85) PAGE 2 <br /> ,�, i <br />