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*al./ STATE I0 NUMBER 00000009409002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> ( ) 07 UNLINED fX) 08 UNKNOWN ( ) 09 OTHER: <br /> 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING l ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l 1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B (CHECKRA PROPRIATE•BOX(ES) ( ( ) 4OPRESSURELEO PIP5 SUCTION CONCRETE-LINED <br /> 06EUNKNOWNTRENCH 07(NONE GRAVITY <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ] 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED 'eES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> f 1 01 f ) 02 f ) 03 <br /> ( ) 01 ( h. 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> f ) OS ( ) 02 ( ) 03 <br /> ( ) O1 f ) 02 ( ) 03 <br /> ( ) <br /> 01 f 1 02 ( ) 03 <br /> f ) 01 f ) 02 f ) 03 <br /> ( l 01 ( l 02 ( ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> "S CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 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 (SIGNAT E) '/ PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> COUNTY CODE <br /> IACMI\:STRAYING AGENCY CITY CO <br /> 1 <br /> CONTACT P, EPSON PHO <br /> DATE OFLAST INS OTICN IN COMP IANCE PERMIT APPROVAL DATE TRANSACTIOf)NN DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> NSC04-070185 (10/18/85) PAGE 2 <br /> `F �� <br />