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�1 <br /> STATE ID NUMBER. 00000011196002 <br /> CONTAINER CONSTRUCTION <br /> E. 1 ) 01 RUBBER LIMED ( 1 02 ALKYD LINING f 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 105 GLASS LINING <br /> (X) 07 UNLINED ( 1 08 UNKNOWN 1 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGRCUlD PIPING: l ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 107 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE lX) 05 SUCTION ( 1 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> f 1 01 VISUAL (X) 02 STOCK INVENTORY 1 ) 04 VAPOR SNIFF WELLS 1105 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CnECA_D YES TO IV•F YOU APE NOT REOUIPED TO COMPLETE THIS SECTION <br /> CUPPENTLY PPEVICUSLY DELETE CASE IIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STOPED STOPED <br /> f I O1 f ) 02 ( ) 03 <br /> 11 01 1 1 02 ( 1 03 <br /> 1 ) Ol ( ) 02 l ) 03 <br /> l ) Ol ( ) 02 l l 03 <br /> ( ) 01 1 ) 02 ( 1 03 <br /> f 1 <br /> 01 ( ) 02 ( 1 03 <br /> I ) 01 ( ) 02 f 1 03 <br /> f ) Ol ( ) 02 ( 1 03 <br /> l ) 01 ( 1 02 ( 1 03 <br /> ( ) Ol ( ) 02 f 103 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTA It1ER LOCATED ON AN AGRICULTURAL FARM? ( ) 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/APIA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AD 'NI S TRAT NO AGENCY - CITY COD! COUNTY CCD! <br /> QtS` 0 <br /> CONT5LA -MSRECTION <br /> A C00! <br /> VV "t I _ 01 <br /> DATE FINCOMPLIANCQ AT! TRANSACTION DAT! IO> <br /> 01 YES 1 ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />