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STATE IO NUMBER 00000009408001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 O1BBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING { ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ):0:7 UNLINED (X) 08 UNKNOWN { 1 09 OTHER: J <br /> F. ( ) O1 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING C ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> t ) 06 TAR OR ASPHALT ( } 09 OTHER- <br /> v PIPING � - - <br /> A. ABOVEGROUND PIPING ( ) O1 DOUBLE-WALLED PIPE { ) 02 CONCRETE-LINED TRENCH ( } 03 GRAVITY <br /> (CHECK APPROPRIATE BOXfESI f } 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN [ ) 07 NONE <br /> B. UNDERGF.OUND PIPING ( ) O1 DOUBLE-WALLED PIPE i ) 02 CONCRETE-LINED TRENCH [ } 03 GRAVITY <br /> (CHECK APPROPRIATE BOXiES) ( ) 04 PRESSURE i ) 05 SUCTION {X) 06 UNKNOWN <br /> { } 07 NONE <br /> VII LEAK DETECTION <br /> DO1 VISUAL ( ) 02 STOCK INVENTORY ( } 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL-�COMPOSITION N OF NOT RMATE To COMPLETE STOREID SECTION UNDERGROUND CONTAINERS <br /> :F YOU CHECKED Yc <br /> CURRENTLY FREVIOLASLY DELETE CASri SIF KNOWN) <br /> CHEMICAL (OC NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( } 02 ( ) 03 <br /> { ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 i ) 031 LLL <br /> i ) <br /> 01 { 1 02 ( } 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 i ) 03 <br /> C ) 01 ( l 02 ( ) 03 -� <br /> { ) <br /> 01 C } 02 ( ) 03 <br /> i ) <br /> 01 ( } 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> EISCO:NTAINER LOCATED ON AN AGRICULTURAL FARM? 4 ) 01 YES (X) 02 HO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> FHONE W/AREA CODE <br /> PEPSON FILING fSIGNA%P E ) <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> ADMINISTRATING AGENCY <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> LOCAL PERMIT ID <br /> ( ) O1 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 110/18/85) <br />