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CONTAINER CONSTRUCTION STATE ID NUMBER 00000004628002 <br /> E• ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING [ ) 04 PHENOLIC LINING ( ] 05 GLASS LINING <br /> ( l 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) O1 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION t ) 04 UNKNOWN ( J 05 NONE <br /> {X) 06 TAR OR ASPHALT ( r 09 OTHER: <br /> VI PIPING <br /> ENG <br /> PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH C J 03 GRAVITY <br /> PRIATE BOX(ES) { ) 04 PRESSURE { ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> PRIATE BOX(ES) ( ) 04 PRESSURE {X) 05 SUCTION ( 1 05 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> t ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS i 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> =F YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> STORED STOZ_D CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( rol ( ) 02 ( ) a3 <br /> M02( ) 02 ( ) 03 <br /> ( ) 02 ( ) 03) 02 ( J 03 1 02 ( ) 03) 02 ( ) 03) 02 ( r a3) 02 ( ) 03) 02 ( ) 03 <br /> LL <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />=CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 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 /> PERSON FILING (SIGNA U E) <br /> PHO WfAREA CODE /fJ+ <br /> 111�o <br /> FOR LOCAL AGENCY USE ONLY <br /> A'OM*NISTRATING AGENCY' <br /> r(c4 CIT WOE COUNT <br /> CODE <br /> CONTACT PEPSCN Vj <br /> PHONE W:AR A CODE <br /> c_ _ fl- Q 4� - 3 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( ) 01 YES ( ? 02 NO LOCAL PERMIT ID # <br />{SC04-070185 (10/18/85) <br /> PAGE 2 <br />