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CONTAINER CONSTRUCTION STATE ID NUMBER 00000045931004 <br /> E ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 103 EPDXY LINING [ ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED i ) 08 UNKNOWN ( 1 09 OTHER: <br /> T 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 1 OS NONE <br /> (X) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE—WALLED PIPE ( ) 02 CCNCRETE—LINED TRENCH { ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( l 04 PRESSURE ( ) OS SUCTION ( ) 0'6 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH <br /> (CHECK APPROPRIATE BOXES) ( } 04 PRESSURE 03 GRAVITY <br /> ( } 06 UNKNOWN ( ) <br /> VII LEAK DETECTION <br /> =( )106 <br /> UAL ( ) 02 STOCK INVENTORY (X) 04 VAPOR SNIFF WELLS05 SENSOR INSTRUMENT <br /> ROUND WATER MONITORING WELLS ( ) 97 PRE5SURE TEST { 1 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUP;ZNTLY PREVIOUSLY DELETE CASK IIF KNOWN) - <br /> STOVeD STOPED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( l 01 ( ) 02 { ) 03 11 <br /> i l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 { l 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 d ) 02 ( ) 03 <br /> i 1 01 ( l 02 ( ) 03 <br /> ( ) O1 [ ) 02 ( 1 03 <br /> f } 01 ( 1 02 ( J 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> =CONTAINEPLOCATED 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 /> PERSON FILING (SIGNATURE) <br /> PHONE W/-.APEA CODE q <br /> 4 f 7 �4 7- <br /> FOR LOCAL AG CY USE ONLY <br /> ADMINIS-PATIN3 AGENCY ♦'1� "T <br /> CITY CODE COUNTY CODE <br /> v �T vF U � � 7 1 <br /> CONTACT PEPSCN " <br /> 1_5e 4 1-j A-"' PHONE W/AREA CODE _ <br /> fl / r/c � l— V � S0 -2 <br /> DATE OF LAST INSP!CTION IN COMPLIANCE <br /> �i PEPMIT APPROVAL DATE TRANSACTION DATE <br /> 01 YES ( ) 02 NO TLOCAL PERMIT IOC <br /> RSC04-070185 (10/18/85) <br /> PAGE 2 <br />