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STATE ID NUh1BER <br /> 00000021915003 <br /> CONTAINER CONSTRUCTION - <br /> E. ( D O1 RUBBER LINED ( ) 02 ALKYD LINING [ ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( D 07 UNLINED (X) 08 UNKNOWN i D 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP { ) 02 VINYL WRAPPING [ l 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ) 05 NONE <br /> C ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: C ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( D 05 SUCTION [ ) 06 UNKNOWN i k 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> [CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( } 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY C ) 04 VAPOR SNIFF WELLS ( } 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST f ) 09 NONE f ) 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 /> STO?ED STOPED <br /> ( } 01 ( ) 02 f ) 03 <br /> ( ) <br /> 01 ( ) 02 f ) 03 <br /> ( ) 01 f ) 02 I } 03 <br /> ( ) 01 ( ) 02 C } 03 <br /> ( D 01 ( ) 02 ( ) 03 <br /> l ) <br /> 01 [ } 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) O1 f ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( D <br /> 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CCNTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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 COPP.ECT. <br /> PEPSON FILING (SIGNATURE) PHO E W/ARE CODE <br /> 14(o3 - 0 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPAT NG AGENCY CITY CODE COUNTY CODE <br /> Lit I <br /> CONTACT PERSON PHONE W/AREA CODE <br /> nA �--,6cA ) L414 ,3 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( 1 02 NO <br /> HSCC4-070155 (10/18/85) PAGE 2 <br />