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STATE ID NUMBER 00000002601001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( l 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X1 08 UNKNOWN ( ) 09 OTHER <br /> F. f 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ] 05 NONE <br /> ( ) 06 TAR OR ASPHALT [ ) 09 OTHER' <br /> VI PIPING <br /> A (BOVECHECK UN I PING APPROPRIATE BOX ES) ( ( 0104 PRESSURELED 11PE 02 05 SUCTION CONCRETE-LINED( ) 06UNKNOWNTR(N)M 07(NONE GRAVITY <br /> B UNN ER DERGROUND <br /> ANO LPPROPRIATE BOX ES) ( ( 0104 PRESSURELEOX) 05 SUCTION CONCRETE-LINED 06EUNKNOWN <br /> TRENOH07(NONE <br /> 3 GRAVITY <br /> VII LEAK DETECTION <br /> TRUMENT <br /> ( [ 01061SUAL GROUND(X) 02 STOCK WATER MONITORING NWELLS (( 11007VAPOR <br /> PRESSURESNIFF <br /> TESTWELLS 1(09 NONE05 ENSO1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> rCUPPIENTLY PREVIOUSLY DELICASUIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED02 f 11 ( ) 02 (1 ( 7 02 ( <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 [ l 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 t ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 Y�(X) NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEPS FILING (SIGN URE1 PRONE W/AREA CODE C / <br /> �9- y66- <br /> FO LOCAL AGENCY USE ONLY <br /> ADM STRA.�NG AGENCY <br /> CITY CODE COUNTY CODE <br /> ' r <br /> N X10 A 6,kA( q L.,OL-ftL D !ST <br /> CONTACT PER ON PHONE W/AREA CODE <br /> c G WAHAM30N 7 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # <br /> 1_l(_ _Q l ] 01 YES ( 7 02 NO <br /> I LFJ O PAGE 2 <br /> HSC04-070185 (10/18/85) <br />