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/ • STATE ID NUMBER 00000021465002 <br /> CONTAINER CONSTRUCTION <br /> E <br /> RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING f 7 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN f 7 05 NONE <br /> 06 TAR OR ASPHALT ( l 09 OTHER <br /> VI PIPING <br /> FA. ABOVEGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> HECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> HECKRAPPROPRIADOUBLE <br /> TE•BOX(ES1 ( ( 0104 PRESSURE-WALLED PIPE <br /> SUCTION CONCRETE 06UNKNOWNNED TR(NCFi 07(NONE <br /> 3 GRAVITY <br /> VII LEAK DETECTION <br /> ( 101 VISUAL ( ) 02 STOCK INVENTORY 1 ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 7 06 GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST (X) 09 NONE ( ) 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 (00 NOT USE COMMERCIAL NAME) <br /> STORED ,STORED <br /> ( r 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( r 01 ( l 02 ( ) 03 <br /> ( ] 01 ( 7 02 ( ) 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> ( 7 <br /> 01 ( r 02 ( 1 03 <br /> f ) 01 ( ) 02 ( 7 03 <br /> ( 1 01 f 7 02 ( ) 03 1 LL <br /> f 1 01 f 1 02 ( 7 03 <br /> )t CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 O1 YE�(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 /> PHONE W/AREA CODE <br /> PEP.SON FILING (SIGNATURE) <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY <br /> CITY CODE COUNTY CODE <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) O1 YES 1 ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />