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• • STATE ID NUMBER 00000028920002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING f ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> ( 1 07 UNLINED ( ) 08 UNKNOWN f 1 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION [ 7 04 UNKNOWN f 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE t 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( ) 05 SUCTION f ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE f ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CMECKEO YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY FPEVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STCPED STORED <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> t 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> f ) 01 ( ] 02 ( ] 03 <br /> ( 1 01 ( ) 02 ( ] 03 <br /> f ) 01 ( ) 02 f 1 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 rFORM HAS BEEN 0 D UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEPSO ING ( TUR PH0 �IAgP q �Q] z�W u43 <br /> FOR LOCAL AGENCY USE ONLY O w <br /> ADMINIST I NG AGENCY( ' CITY QODE COUNTY CODE <br /> CONTSSCT PEPRI <br /> \.( ( 61'4 (� pNO �W'ARE)7,)3I W <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> f 1 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />