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STATE I() NU 5ER 00ocooli293001 <br /> CONTAINER CONSTRUCTION J <br /> rE. ( i41 RUBBER LINED .. ) 02 ALKYO <br /> UNKNOWN LENiN09 OTHER3 EPDXY LINING ( a 04 p}{ENOLIG LINING I ) 05 GLASS LINING <br /> ( 1 07 UNLINED tX( J O1 POLYETHLENE WALT t())02QVIINYYLRWRAPPING <br /> ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASF <br /> VI PIPING <br /> L(CHECK <br /> EGROUND PIPING ( 1 O1 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> CK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 45 SUCTION t 1 Ob UNKNOWN _(Sc) 07 NONE <br /> B. RGROUND PIPING ( ) O1 DOUBLE—WALLED PIPE ( a 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> APPROPRIATE BOX(ES) ( ) 04 PRESSURE iX) 05 SUCTION ( i 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( fi�06 <br /> L tX) 02 STOCK INVENTORY ( ) 007V PORPRESSNIFFURE WE LLS J(09 05 SENSOR INSTRUMENT <br /> "—rOUND WATER MONITORING WELLS y <br /> VIII CHEMICAL COMPOSITION OF MAID DRIALS D COMPLETE ORED SIN Io UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU .APE NOT REQ <br /> CURRENTLY PRE'vIOUSLY DELETE <br /> CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( a 01 ( a 02 ( ) 03 <br /> ( } 01 t a 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 t ) 02 E ) 03 <br /> ( ) 01 ( } 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( J 03 <br /> ( ) 01 f } 02 ( ) 03 <br /> ( ) 01 E ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03LLU <br /> t 1 01 ( ) 02 t ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> I� <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 /> -— PHONE W/ARE CODE <br /> PEPS FILING 1SI0NA E <br /> OR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> XNNIISTPATING AGENCY <br /> PHONE W/AREA CODE 0 <br /> P PEON y�^�n [ I ` 'l U �� <br /> TRANSACTION PATE LOCAL PERMIT ID # <br /> ST INSPECTION IN COMPLIANCE <br /> PERMIT APPROVAL DATE <br /> 91 YES ( ) 02 NO <br /> OO KK!! Y ` • # PAGE 2 <br /> 10/18/85) <br />