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STATE IO NUMBER 00000916301091 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( l 04 PHENOLIC LINING { ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN { l 05 NCNE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: f l 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION [ ) 06 UNKNOWN { ) 07 NONE <br /> VII LEAK DETECTION <br /> ( l pl VISUAL t ) D2 STOCK INVENTORY i 104 VAPOR SNIFF WELLS ( ] 05 SENSOR INSTRUMENT <br /> i ) D6 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKEO YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PPEVICUSLY DELETE CASTE (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( ) O1 t 1 02 ( 3 03 <br /> t ) 01 ( ) 02 i ) 03 <br /> ( ) 01 € 1 02 ( 3 03 , I I I 1 Lt <br /> { ) 01 ( ) 02 f ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( ) 01 { ) 02 ( ) 03 <br /> t ) 01 ( ) 02 [ ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FCR POSSIBLE SYNONYMS <br /> FISCONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FORK' HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEPSCN FILING (SIGNATURE) PHONE W/AREA CODE p <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPPOVAL DATE TRANSACTION COTE LOCAL PERMIT ID # <br /> d ) OI YES ( 1 02 NO <br /> PAGE <br /> HSC04-070185 (10/18/85) 2 <br />