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,TATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04 PHENOLIC LINING ( ) 05 GLASS LINING Y <br /> ( D 07 UNLINED ( ) 08 UNKNOWN t ) 09 OTHER: I <br /> ( D <br /> 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> C 106 TAR OR ASPHALT ( ) 09 OTHER: <br /> II PIPING <br /> { <br /> R. ABOVEGROU14D PIPING= ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY --1 <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04' PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE 11 <br /> 3. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> /II LEAK DETECTION <br /> ( ) <br /> 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUDiD WATER M0►(ITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( D 10 OTHER: <br /> /III CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQU:RED TO COMPLETE THIS SECTION <br /> I <br /> :URRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t ) 01 ( ' 02 ( ' 0311111 I IL1 I L I I <br /> ( ) 01 ( ) 02 ( ) 03I I I 11 1 1 11 1 1 1 <br /> C ) 01 ( ) 02 ( l 03 I I I I� ,I �I �I II iL�I -- <br /> ( ) 01 t ) 02 ( ) 03 I L l� 1 -- - <br /> ( , <br /> 01 ( ) 02 ( ) 03 L H H I I I_1_1_L11 --_-- ------- <br /> ( t 01 O 02 O 03 1 1 1 1 1 <br /> O <br /> 01 O 02 O 03 <br /> ( ) 01 ( ' 02 O03_1_1 <br /> ( ) <br /> 01 ( l 02 ( ) 03 <br /> -( ) 0'1 (_D 02—( 1 03 I.L�Ll_LLLU H .IIS CONTAINER CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( D 02 NO <br /> HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEPSON FILING (SIGNATUPE) -_- -- --HONE W/AREA CODE -�� <br /> COR LOCAL AGENCY USE ONLY <br /> AOMIttISTPATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PEP,SON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE IPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> i ( ) 01 YES ( ) 02 NO <br /> ISC04-070185 PAGE 2 <br /> i <br /> 3SN3dX3 1 hD J :.V 03z)naoud32� <br />