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STATE ID `NUMSER 00000062251006 <br /> CONTAINER CONSTRUCTION <br /> Z. <br /> E. 6 ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING f )r 05 GLASS LIN-1NG <br /> (X) 07 UNLINED f ) OB UNKNOWN ( ) ,09 OTHER <br /> F. E ) 01 POLYETH,LENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODICPROTECTIONt ) 04 UNKNOWN t l 05 NONE <br /> E ) 06 TAR OR ASPHALT t J 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (:CHECK APPROPRIATE BOX(ES) f ) '04 PRESSURE tSLOS SUCTION .( l 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> t"CHECK APPROPRIATE SOXtES) ( ) 04 PRESSURE: ( ) .05 SUCTION t J 06 UNKNOWN 0< 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR; INSTRUMENT <br /> t ) 06 GROUND WATER MONITORING WELLS 04 07 PRESSURE TEST ( ) 09 NONE t ) 10 OTHER: <br /> VII:I CHEMICAL COMPOS:ITIO'N OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> 'TF YOU'CHECKED YES TO IV-F YOU ARE NOT REgUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORZO <br /> C Q-1' ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( )" <br /> 01 : t ) 02 t ) 03 <br /> t- ) 01 ( ) 02 f l 03 <br /> ( ) <br /> al t ) :02 ( ) 03 <br /> ( ) 01 : ( ) 02 ( ) 03 <br /> ( ) Ol ( ),02 f ) 03 <br /> s <br /> € t 01 f ) 02 L ) 03 <br /> t ) 0.1; ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL. FARM 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 PI I (SIGNATU ) PHONE pW/AREA CODS 7 � <br /> vi <br /> FOR LOCAL AGENCY USE ONLY <br /> §ADMINISTRATING AGENPY CITY CODE COUNTY CODE <br /> 3 <br /> q jn aeaji� 32 <br /> " <br /> CONTACT PERSON PHONE W/AREA CODE <br /> .2®1 - <br /> DATE OF LAST INSPECTION ]IN COMPLIANCE JPERMIT APPROVAL DATE I-TRANSACTION DATE LOCAL PERMIT ID # <br /> 4 ( ) 01 YES ( ) 02 NO <br /> ti 04-030185 f10118/85) , �" PAGE 2 <br /> 1. <br />