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STATE 10 NUMBER 00000001798006 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( D 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (.X) 08 UNKNOWN ( ) 09 OTHER <br /> F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION IX) 04 UNKNOWN ( ) 05 NONE <br /> t ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> S. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( } 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL t ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( } 05 SENSOR INSTRUMENT <br /> ( } 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST t ) 09 NONE { ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED INUNDERGROUNDCONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CA$# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> (X) 01 ( ) 02 ( ) 03 ASPHALT,- PAVING GRAD 'AR4006 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 03 <br /> t 3 01 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> f ) 0.1 ( ) 02 ( ) 03 <br /> ( D 01 ( ) 02 ( ) 03 <br /> t ) <br /> 01 ( ) 02 ( ) 03 <br /> ( } <br /> 01 ( ) 02 ( ) 03 <br /> �( CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CDNTAINER LOCATED ON ANAGRICULTURALFARM? t D 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 (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID ft <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/65) PAGE 2 <br />