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STATE ID NUMBER 00000047929001 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED 1 1 02 ALKYD LINING 1 ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED IXI 08 UNKNOWN ( 1 09 OTHER: <br /> F. f 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> 1. 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING ( 1 01 DOUBLE-WALLED PIPE I 1 02 CONCRETE-LINED TRENCH l ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (. 1 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN 1 ) 07 NONE <br /> B. UNDERGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE f 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL 1 ) 02 STOCK INVENTORY I ) 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS I ) 07 PRESSURE TEST (X) 09 NONE l ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF 1'0" CHECKED )ES -0 IV-F "CU --I NOT '--JIi ED TO COMPLETE THIS SECTION <br /> CUFiENTLY -cEV:CUSLi DELETE CASC 'IF 1NC;:N1 CHEMICAL IDO NOT USE CCMMEPCIAL NAME ) <br /> STC=ED STC-EO <br /> l ) 01 ( 1 02 f ) 03 <br /> f 1 01 ( 1 02 ( 1 03 <br /> 1 1 01 ( 1 02 1 ) 03 <br /> ( ) Ol f l 02 f l 03 <br /> ( 1 Ol ( ) 02 f ) 03 <br /> f 1 01 ( 1 02 1 ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> f ) Ol ( ) 02 1 1 03 <br /> 1 ) 01 ( ) 02 1 ) 03 I -- <br /> f 1 <br /> 01 ( ) 02 1 ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (X1 02 NO <br /> I <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEPSCN FIIINO (S:GNATUiEI PHONE W/APEA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> =M-:N:STATINO AGENCY CITY CODE COUNTY CODE <br /> CCNTACT PEiSCN PHONE W./APEA CODE <br /> OF LAST :NSPECT:ON IN COM={:aNCE FEiMIT APPPOVAL DATE TPANSACTION OATS lOCal PECMIT :0 d <br /> �1 01 IES t ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />