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STATE ID NUMBER 00000006823002 <br /> CONTAINER CONSTRUCTION <br /> E. i 1 01 RUBBER LINED i l 02 ALKYD LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> M 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER* <br /> F. ( ) 01 POLYETHLENE WRAP ( ! 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( } 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( J 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE C 1 02 CONCRETE-LINED TRENCH ( J 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( J 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( J 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES1 i 1 04 PRESSURE ( ) 05 SUCTION C 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> F;( <br /> ) 01 VISUAL (X1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS t 1 05 SENSOR INSTRUMENT <br /> 1 06 GROUND WATER MONITORING WELLS { 1 07 PRESSURE TEST t ) 09 NONE ( 1 10 OTHER: J <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 /> CUPPENTLY PREVIOUSLY DELETE CASG tIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( ) 01 f 1 02 ( J 03 <br /> ( 1 01 t } 02 t 1 03 <br /> t 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( 1 02 E 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 f 1 02 ( ) 03 <br /> ( ] 01 t ! o2 ( ) 03 <br /> ( ! 01 ( ) 02 1 1 03 <br /> t 1 01 ( 1 02 ( ) 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 /> PEP.SON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCRL PERMYT IC 2! <br /> ( ) 01 YES ( ) 92 NO <br /> HSC04-0 0135 (10/18/85) PAGE 2 <br />