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../ <br /> STATE IO NUMBER 00000013101001 <br /> CONTAINER CONSTRUCTION <br /> E. ( I 01 RUBBER LINED ( ) 02 ALKYD LINING ( ] 03 EPDXY LINING l 1 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP l 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( l 04 UNKNOWN ( 1 05 NONE <br /> (X) 06 TAR OR ASPHALT ( 7 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION l ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ),�01 DOUBLE-WALLED PIPE ( 7 02 CONCRETE-LINED TRENCH ( 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( l ACNE <br /> VII LEAK DETECTION <br /> ( l O1 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS [ ) 05 SENSOR INSTRUMENT <br /> ( l 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE ( ) 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 /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> f ) O1 ( 1 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> l ) <br /> 01 ( 1 02 ( ) 03 <br /> l ) 01 ( 7 02 ( ) 03 <br /> f ) 01 ( 1 02 1 l 03 <br /> ( 7 <br /> 01 f 7 02 ( ) 03 <br /> 1 7 <br /> 01 ( 1 02 ( 1 03 <br /> l ) 01 ( 7 02 1 1 03 <br /> ( ) <br /> 01 ( 1 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 UN R'THE PENALTY OF PERJUU AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEPSON FILING (SIGNATURE PHONE W/AR CCDE D <br /> FOR LOCAL AGENCY USE ONLY <br /> AD MI Ni STPAT NO AGENCY / CITY COIJE COUNTY CODE <br /> g 'SIL <br /> CONTACT EPSON /` PHONE W/AREA ODE <br /> .DATEG1 a t):�I 13 -.A- <br /> DATE <br /> OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 01 YES ( I 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> S�l <br /> f <br />