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STATE IO NUMBER 00000011516002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN f ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 1 05 NONE <br /> (X) 06 TAR OR ASPHALT ( 109 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( ) C4 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) ( 1 04 PRESSURE (X) 05 SUCTION ( l 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> ("XT 01 VISUAL (X) 02 STOCK INVENTORY f l 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( l 07 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 /> I ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 f ) 03 <br /> ( ) 01 ( l 02 f ) 03 <br /> [ ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( 1 02 ( 1 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES ( ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENAon L PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEP ON FILI 0 <br /> F R LOCAL AGENCY USE ONLY <br /> AOM'_NISTRATI NG AGE NLYCITY COD! COUNTY COD! <br /> Co44 / <br /> NT T PERSON PH E W AREA CODE <br /> GATE OF LAST INSPECTION IN COMPLIANCE PCRMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( i 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> y <br />