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STATE ID NUMBER 00000031635001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING [ ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ] 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 7 04 UNKNOWN [ ) 05 NONE <br /> (X) 06 TAR OR ASPHALT f ] 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXfES) ( 1 04 PRESSURE ( 1 05 SUCTION (2F11 06 UNKNOWN (?S07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX LKT g <br /> BOX(ES) ( ) 04 PRESSURE 05 SUCTION l ) 06 UNKNOWN Sff 07 NONE <br /> VII LEAK DETECTION <br /> TRUMENT <br /> -5r, <br /> 06 <br /> 03VISUAL <br /> GROUND ER MONITORINGNWELLS (('1Y 0704 VPRESSUREAPOR FLL <br /> TEST �(09 NONE05 EN{ ) 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 /> CURPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( 1 01 ( 1 02 ( ] 03 <br /> f l 01 f ] 02 f ] 03 <br /> ( ) <br /> 01 [ 102 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( 1 02 ( ] 03 <br /> ( ) <br /> 01 ( ] 02 f ] 03 <br /> ( ] <br /> 01 ( l 02 [ ] 03 <br /> ( ) <br /> 01 ( l 02 ( ) 03 <br /> ( ) O1 f 7 02 f 1 03 <br /> ( ) 01 ( l 02 ( ] 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINERLOCATED ON AN AGRICULTURAL FARM? ( ) O1 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 /> PEPS FILING (SIGN URE) PRONE W/A EA CODE <br /> � — 2 2 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADM,1 IST RATIN^u GE NCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> e a.f\ Ter 1EJ -- -9891) <br /> DATE OF LAST INSPECTION IN CO LIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES f ) 0� PAGE 22�NNO <br /> O S/ _ /�G�(/ ✓�/�L� ���� <br /> HSC04-070185 [.10/18/851 �� <br />