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• STATE ID NUMBER 00000008382010 <br /> CONTAINER CONSTRUCTION <br /> E. ( 7 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING [ ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) OB UNKNOWN ( ) 09 OTHER <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f 103 CATHODIC PROTECTION ( ) 04 UNKNOWN f ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( J 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 7 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ( ) 05 SUCTION lX) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f 7 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 /> f l 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 7 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE f 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) 01 f ) 02 ( ) 03 111313101210171 -XYLENE, ALL ISOMERS <br /> ( D 01 ( } 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 7 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 7 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> f l 01 f 1 02 ( ) 03 <br /> ( ) 01 ( 7 02 ( ) 03 <br /> ,( CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEPSO F ISIGN ` \ PHONE W/AREA CODE <br /> C; �(�� <br /> FOR LOCAL AGEN SE ONLY <br /> lb <br /> ADM I NIST R ATI 3 AGENCYI n CITY CODE <br /> �. ,, �- I AS_Vn CA 1 .3 <br /> OOE_ COUNTY CCDE <br /> CONTA^ ) RS(N /� , �) PHONE W�REA)CODE <br /> L1610- <br /> OA <br /> I610_ !'�� I <br /> DATE OF LAST INSPECTION-u. IIN COMPLIANCE PERMIT APPROVAL DATE CTRANSACTION'-tDATE �l LOCAL PERMIT ID 1t <br /> ( 1 <br /> 01 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />