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CONTAINER CONSTRUCTIONSTATE ID NUMBER 00000009692002 <br /> E. ( 1 0ERB ER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> (XNLINED f ) 08 UNKNOWN ( ) 09 OTHER:F. ( ) 01ETHLENE WRAP ( i 02 VINYL WRAPPING ( } 03 CATHODIC PROTECTION f 1 04 UNKNOWN ( 1 05 NONE <br /> (X) AR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: C ) al DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH <br /> (CHECK APPROPRIATE BOX ( ) 03 GRAVITY <br /> BOX(ES) ( 1 04 PRESSURE (X1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> I ) 06 GROUND WATER MQNITORING WELLS [ ) 07 PRESSURE TEST ( 1 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 REQUIRE© TO COMPLETE THIS SECTION <br /> CURRENTLY PF-cVIOUSLY DELETE CAS4 (IF KNOWN) <br /> STORED STOPED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( ) 01 ( 1 02 ( D 03 <br /> ( 1 01 i ) 02 f ) 03 <br /> ( } 01 ( 1 02 ( 1 03 <br /> c 1 01 ( 1 02 i ) 03 <br /> ( 1 01 c 1 02 i ) 03 <br /> ( ) OI ( 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) a3 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> i ) O1 ( 1 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> EISCONTAINER 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 CORRECT. <br /> PEPSON FILING (S ATUPE) - <br /> PHONE W/'AREA CODE <br /> fve-33 r/ <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN` 'PATINE AGENCY <br /> CITY CODE COUNTY CODE <br /> (28 1A1N LoC�L. i����N Da.� <br /> CONTACT PSON <br /> ILI PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE 7-� vif-33 <br /> FEFMIT APPROVAL DATE TRANSACTION DATE <br /> 01 YES ( ) 02 NO LOCAL PERMiT IO it <br /> ISC04 070185 (10/18/85) <br /> PAGE 2 <br />