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STATE ID NUMBER 00000042134001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING (X) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER, <br /> F. ( ) 01 POLYETHLENE WRAP i ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT t ) 09 OTHER, <br /> VI PIPING <br /> A. ABOVEGROUND PIPING, ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE t ) 10 OTHER, <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKEC YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPFENTLY PREVIOUSLY DELETE CRS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STOPED STORED <br /> (X) 01 ( l 02 t ) 03 11101151110111 f METHYL IOSBUTYL KETONE <br /> (X) 01 t l 02 ( ) 03 1110181818131 * TOLUENE (METHYLBENZENE)AROMATIC HYDROCARBON LOW ANALINE) <br /> (X) 01 t ) 02 I ) 03 16171614111 * ACETONE (DIMETHYL KETONE) 2-PROPANONE) <br /> (X) 01 ( ) 02 ( ) 03 111111111.5191_1 ETHYLENE GLYCOL MONOETHYL ETHER ACETATE (2-ETHOXYETHANOL ACE <br /> (X) 01 ( l 02 ( ) 03 16141117151 ETHYL ALCOHOL <br /> (X) 01 ( ) 02 ( ) 03 19111210131 NAPTHALENE <br /> (X) 01 ( ) 02 ( 1 03 1 1 1 1 1 1 1 1 1 1 1 1 1 PARAFFINS <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> r ) O1 [ ) 02 i 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 /> PEP.SON FILING (SIGNATURE ) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 0Y YES ( ) 02 NO <br /> HSC04-070185 (10/18/851 PAGE 2 <br />