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STATE 20 NUMBER 00000061953004 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER. LINED ( ) 02 ALKYD LINING ( ] 03 EPDXY LINING ( 1 04 PHENOLIC LINING l ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER <br /> F. ( 1 01 POLYETHLENE WRAP 1 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A (CHECK APPROPRIATE BOXES) (f 011040 RESSURELE( P1PE 02 05 SUCTION CONCRETE-LINED <br /> IR06EUNKNOWN� 3 GRAVITY <br /> ( ) 07ENCH (NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH 0( 03 GRAVITY <br /> ICHECK APPROPRIATE BOXIES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN (4 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL ( 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORI WELLS (�l 07 PRESSURE TEST ( 1 09 NONE ( l 10 OTHER= <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO ZV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED _ <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 _ <br /> f 1 01 t ) 02 { 1 03 <br /> ( 1 01 ( 1 02 O 03 <br /> ( 1 0l f ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 O 03 <br /> l ) 01 f ) 02 ( ) 03 <br /> 11 O1 ( 1 02 f 1 03 I I <br /> f ] Ol f 102 ( 1 03 <br /> ( ] 01 ( ) 02 ( ) 03 <br /> • CHECK STATE BOARO CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 CQ E <br /> FOR LOCAL AGENC USE ONLY <br /> AOMEN�STRAT� AGENCY n CITY CODE COUNTY CODE <br /> CONTACR N /l PtPONE W/AREA CODE <br /> DATE OF LAST vINSPECTION IN COMPLIANCE PERMIT APPROVAL DAT[ TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES ( ) 02 NO <br /> 4SC04-070185 (10/18/85) PAGE 2 <br />