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STATE ID NUMBER 00000001669004 <br /> CONTAINER CONSTRUCTION <br /> r <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> t ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. [ ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING [ ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( l 05 NONE <br /> t ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION (X) 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 ( ) 05 SUCTION ( } 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> (X1 01 VISUAL ( } 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( l 06 GROUND WATER MONITORING WELLS t ) 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHERz <br /> VIII CHEMICAL COMPOSITION OF 'MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECVED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# SIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 [ 103 <br /> 01 ( 1 02 ( 1 03 <br /> ( 1 01 f 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 [ ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X1 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/APEA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT ;EPSON PHONE W/ARE.A CODE <br /> DATE OF LAST INSPECTION ZN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> f 3 O1 YES S ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />