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CONTAINER CONSTRUCTION STATE ID NUMBER 00000013931002 <br /> E <br /> 1 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING 1 1 05 GLASS LINING <br /> 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 OS NONE <br /> ) 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> VI PIPING <br /> FAABOVEGROUND PIPING: ( 1 O1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH03 GRAVITY <br /> (CHECKAPPROPRIATE BOX(ES) ( ) 04 PRESSURE f 1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> UNDERGOUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST (X) 09 NONE ( l 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO :V-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK IIP KNOWN) <br /> STORED STOPED CHEMICAL (DO NOT USE COMMERCIAL NAM!) <br /> l ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> 1 ) Ol ( 1 02 ( 1 03 <br /> f 1 <br /> 01 ( ) 02 ( 103 <br /> 1 1 01 ( ) 02 ( ) 03 <br /> 1 I <br /> 01 ( ) 02 f ) 03 <br /> 1 ) 01 l ) 02 f 1 03 <br /> f 1 01 ( ) 02 ( 7 03 <br /> l ) O1 1 1 02 ( 1 03 <br /> f 1 <br /> 01 1 ) 02 ( ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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 /> PEPSON FILING (SIGNATURE ) PMON! W/ARCA COD! <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINZSTRATZNO GENCY CITY CODE COUNTY CODE <br /> CONTACT EPSON <br /> PHO W/ARCA COD! <br /> y- 3 <br /> DATE OF LAST :NSPCCTION ZN CO LZANC! 7 <br /> PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( ) O1 <br /> VMS f ) 02 NO LOCAL PREMST IO R <br /> HSC04-070185 (30/18/85) <br /> PAGE 2 <br />