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STATE ID NUMBER 00000021368002 <br /> CONTAINER CONSTRUCTION <br /> E ( 1(X1 01 RUBBER LINEDf 1 OS UNKNOWN LINING OTHER: EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 07 <br /> NED <br /> F ( 1(X) 06al LTARHORNASPHALT fI11009VINYL <br /> OTHERWRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( 1 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f 1 O1 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE H41 05 S CT 07 NONE <br /> ( ) 06 UNKNOWN ( l <br /> VII LEAK DETECTION <br /> (bk( 01VSUAL061 GROUND( <br /> X) 02 STOCK INVETOYWATER MONITORINGNWELLS (VC)007V PRESSUREAPOR FTESTLLS 1(09 NONE05 ENSO1 10S <br /> OTHER: <br /> VIII CHEMICAL sON POSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> YOU <br /> CHECKED EoNOT RIo SID <br /> CURRENTLY PPE'JICUSLY DELETE CAS# (IF KNOWNI <br /> CHEMICAL IDD NOT USE COMMERCIAL NAME) <br /> STORED STO'ED <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 f ) 02 ( ) 03 <br /> ( 1 Ol ( 1 02 ( ) 03 <br /> ( ) Ol f ) 02 f ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> it CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 Ol YES (X) 02 NO <br /> (HIS FORM HAS BEEN COMPLETED UNDER <br /> THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PHONE W/AREA CODE C3TLr ` I <br /> pEPSON FILING.(SIGNA URE) 2 2 2 <br /> ,=OR LOCAL AGENCY USE ONLY COUNTY CODE <br /> cxry cooE 3 y <br /> 40 NI STR A7 AGENCY <br /> . py�pNE W)/AREA CODE <br /> CONTACT P RS N/ /_/�> CGOq y7? ?- ! <br /> ��{ / ` LOCAL PER <br /> ID # <br /> LATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> Ol YES ( 1 02 NO <br /> d Y PAGE 2 <br /> HSC04-070185 (10/18/85) • �� � <br /> 1 <br />