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U� <br />CONTAINER CONSTRUCTION <br />( <br />. STATE ID NUMBER 00000011196001 <br />E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( l 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. f 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION f ] 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT ( 109 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE lX) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( 1 01 VISUAL (X) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST ( 109 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 <br />STOPED <br />PREVIOUSLY <br />STOPED <br />DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( 1 O1 <br />( ) 02 <br />( 103 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) OS <br />( ) 02 <br />( 1 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />! ) 01 <br />( ) 02 <br />( ) 03 <br />l ) 01 <br />( ) 02 <br />( ) 03 <br />1 ) 01 <br />( ) 02 <br />( 103 <br />f ) Ol <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( 103 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />w CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES fX) 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 />GEGSON FILING (SIGNATGPE) PHONE W%AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />AOMINiSTRATING AGE YC% <br />CITY CODE <br />39 <br />CCUNTI CODE <br />CONTACT PEPSON <br />PHO <br />C4jlAR <br />A CODE <br />DATE OF LAST INSPECTION <br />LOCAL PERMIT I0 K <br />IN COMPLIANCE <br />( ) 01 YES 1 1 11 NO <br />PER <br />TION DATE <br />IHSC04-070185 110/18/851 <br />0 <br />0 <br />PAGE 2 <br />