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CONTAINER CONSTRUCTION STATE ID NUMBER 00000004628004 <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER= <br /> F. f ) 01 POLYETHLENE WRAP i 1 02 VINYL WRAPPING ( ] 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( l 05 NONE <br /> t ) 06 TAR OR ASPHALT ( ] 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE i 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( ] 04 VAPOR SNIFF WELLS ( r 05 SENSOR INSTRUMENT <br /> { 1 06 GROUND WATER MONITORING WELLS i ] 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 /> FCUITLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL {p0 NOT USE COMMERCIAL NAME) <br /> D STOPED <br /> 1 ( ] 02 ( 1 031 ( ) 02 ( 1 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( r 03 <br /> ( ) 01 ( 1 02 ( ] 03 <br /> ( 1 O1 ( 1 02 ( ) 03 <br /> E r 01 ( ) 02 ( l 03 <br /> ( ) 01 ( ) 02 f 1 03 <br /> ( l 01 i 1 02 ( l 03 <br /> ( 1 0'I ( ) 02 ( J 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> EISCC�NTA�INEROCATED �OHANAGRICULTURAL FARM? [ ) 01 YES (X) 02 N0 <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEP F;LIN3 ( IG E) <br /> P ONE W: REA CODE <br /> FOR LOCAL AGENCY U ONLY <br /> ADMINISTPATING AGENCY CITY CODE <br /> sa COUNTY CODE <br /> CONTACT PERSON `-� PHONE WIAREA CODE <br /> r c c } d�LAC 4(p —3� <br /> DATE OF LAST INSPECTION IN COMIANC PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( ? 01 YES ( ) 02 NO LOCAL PERMIT ID # <br /> ISC04-070185 (10118/85) <br /> PAGE 2 <br />