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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. [ 1 01 RUBBER LINED 4( 1-02 ALKYD LINING t ) 03 EPDXY LINING l 1 04 PHENOLIC LINING [ 1 05 GLASS LINING <br /> ( 1 07 UNLINED (,4) O8 UIIKFIOWN 1 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP i 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> ( .l 06 TAR OR ASPHALT [ 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t 1 05 SUCTION [ 1 06 UNKNOWN t 1 07 NONE <br /> B. UttDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE E ) 02 CONCRETE-LINED TRENCH [ _L3 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE l 105 SUCTION [ ) 06 UNKNOWN l 1 0T NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( ) 02 STOCK INVENTORY [ 1 04 VAPOR SNIFF WELLS t 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GP,OU14D WATER 110F11TORING WELLS [ l 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER: <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 /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> F 1 01 O 02 ( ) 03 <br /> ( 1 01 ( 1 02 t 1 03 <br /> ( 1 01 ( ) 02 ( ) 113J 1 LLI I I I_ <br /> ( 1 01 l ) 02 i 1 03 <br /> ( 7 01 ( 1 02 ( 1 03 11 1 U_LL I 1 .1-1 1 - <br /> 02 1 1 0iL1 1 1 1 1 1 1 1 1 1 L 1 <br /> ( 1 01 [ 1 02 1 ) 03 <br /> ( 1 01 ( 1 02 1 ; <br /> ( 101 1102 1103 LIII111111 � 11i - <br /> r <br /> LSCO!ITAINER LOCATED ON AN AGRICULTURAL FARM? [ 1 01 YES (>6 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 FIL;-G S�SIGNAT E) PHONE/f W//AREA CODE <br /> {�C� <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATINCi AGENCY CITY CODE COUNTY CODE <br /> LocaR 4cc�_Hj��6 <br /> l tL <br /> CONT CT %P�°FS N C v ` PHO E W/AR CODE ] <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION GATE LCCAL PERMIT ID # <br /> f 1 01 YES ( 1 02 ND <br /> PAGE <br /> HSC04-070185 2 <br />