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0 0 <br /> STATE ID NUMBER 40040005986003 <br /> CONTAINER CONSTRUCTION <br /> E. f 1 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> F. [ ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> t ) 06 TAR OR ASPHALT t ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: t 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION [ ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL �02 STOCK INVENTORY t l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) D6 GROU S (X) 07 PRESSURE TEST ( ) 09 NONE ( l 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKEC' ''(ES TO IV-F YOU APE NOT RECUIPEO TO COMPLETE THIS SECTION <br /> CJ-PENTLY PREVIOUSLY DELETE C.AS:t (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( ) 01 ( ) 02 t ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> t 1 01 ( ) 02 [ ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( k 02 ( ) 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> [ ) <br /> 01 f ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 t k 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAIN€R LOCATEO ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY CF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEPSON FILING (S- 'FTUPF) `� ` PHONE WJAREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/APER CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( ) 01 YES I 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />