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STATE ID NUMBER 00000031604003 <br />CONTAINER CONSTRUCTION <br />( ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( J 05 GLASS LINING <br />(XJ 07 UNLINED f ) 08 UNKNOWN i 1 09 OTHER'- <br />01 <br />THER01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT ( J 09 OTHER: <br />iVI PIPING <br />A. ABOVEGROUND PIPING: { <br />l 01 DOUBLE -WALLED PIPE <br />f ) 02 <br />CONCRETE -LINED TRENC ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />( l 04 PRESSURE C ) 05 <br />SUCTION <br />( l 06 UNKNOWN (.107 <br />NONE <br />B. UNDERGROUND PIPING: { <br />1 01 DOUBLE -WALLED PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />f ) 04 PRESSURE (X) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 <br />NONE <br />iVII LEAK DETECTION <br />( ) 01 VISUAL (X) 02 STOCK INVENTORY i ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />[ ) 06 GROUND WATER MONITORING WELLS X) 07 PRESSURE TEST ( l 09 NONE ( ) 10 OTHER <br />I VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YCU CHECKED YES TO IV -F YOU APE NOT RE^wUIPED TO COMPLETE THIS SECTION <br />CUPEENTLY <br />STORED <br />PREVIOUSLY <br />STDFED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />E ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( 1 02 <br />( ) 03 -- <br />C ) 01 <br />( ) 02 <br />t ) 03 <br />( ) 01 <br />f ) 02 <br />( 1_03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( l 03 <br />E ) 01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />C ) 03 <br />( ) 01 <br />t ) 02 <br />( l 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />S CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( J 01 YES (crop- NO <br />THIS FORM HAS BEEN COMPLET U DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PEPSON FILING (SIGNATUPE) 1/� /,j PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY <br />CCNTACT PERSON <br />CITY CODE <br />PHONE W/AREA CODE <br />COUNTY CODE <br />GATE OF LAST INSPECTION �IN COMRLI.ANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />O1 YES ( ) 02 NO <br />IHSC04-070185 (10/18/85) PAGE 2 <br />0 0 <br />