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STATE ID NUMBER 00000002250011 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( 1 07 UNLINED (X) OB UNKNOWN f 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP (X) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( I OS NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( 1 05 SUCTION l ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> I 1 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE ( 1 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 CASS (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> (X) 01 ( ) 02 ( 1 03 ASPHALT, EMULSIFIED SS-1-H SEALER <br /> ( 1 01 [ ) 02 ( 1 03 <br /> ( ) O1 ( 1 02 ( 1 03 <br /> f ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( ) Ol ( 1 02 ( ) 03 <br /> f 1 O1 ( 1 02 ( 1 03 <br /> 1 ) 01 ( 1 02 ( l 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> 1 1 01 ( 1 02 1 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS 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 /> PEPSILING (SIONATU ) PHONE W/AREA CODE <br /> 98z s <br /> F LOCAL AGENCY USE ONLY <br /> ADMINISTRATINO AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> OF LAST INSPECTION IN COMRIIANCE PERMIT APPROVAL DAT! TRANSACTION DATE LOCAL PERMIT ID R <br /> ( ) O1 YES ( ) 02 NO <br /> 5 (10/18/65) PAGE 2 <br />