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STATE ID NUMBER 00000031640002 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( } 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION E ) 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> -VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE E ) 02 CONCRETE-LINED TRENCH 3 GRAVITY <br /> (CHECK APPROPRIATE. BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE { ) Ort CONCRETE-LINED TRENCH 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( } 05 SUCTION ( ) 06 UNKNOWN t } 07 NONE <br /> VII LEAK DETECTION <br /> ( 3 01 VISUAL Qbd 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> t D 06 GROUNTTMR MONITORING WELLS O7 PRESSURE TEST ( ) 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 ( ) 02 ( ) 03 <br /> ( } 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t } 01 ( ) 02 t ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02,_ ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 N0 <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEPS FILING {SIGNATURE) PHONE W/ARE.A CODE EJ <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING, AGENCY CITY CODE COUNTY CODE <br /> sCcC <br /> IZ <br /> CONT4CT EPSON PHONE W/AR A CODE <br /> ca a- — <br /> DATE OF"LAST INSPECTION IN COMPLIANCE FMI <br /> RT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID' at <br /> 01 YES ( ) 02 NO <br /> HSC64-070185 (10/18/85) ! • PAGE 2 <br />