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FY.P ll'tin._ STATE ID NUMBER 00000011195002 CONTAINER CONSTRUCTION E. l ) 01 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING f 1 04 PHENOLIC LINING f ) 05 GLASS LINING IX) 07 UNLINED ( ) 08 UNKNOWN f 109 OTHER: F. 1 ) 01 POLYETHLENE WRAP 1 ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION f ) 04 UNKNOWN (Xl 05 NONE I 1 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY (CHECK APPROPRIATE BOXIES) ( ) 04 PRESSURE I l 05 SUCTION 1 1 06 UNKNOWN 1 1 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN 1 1 07 NONE VII LEAK DETECTION ( 1 01 VISUAL (X) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT I 1 06 GROUND WATER MONITORING WELLS 1 107 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CH!CK!0 'ES TO IV-F YOU APE NOT RECUIPED TO COMPLETE THIS SECTION CJPPENTLY PREVIOUSLY DELETE CAER IIF KNC'<NI CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STOPED ( 1 01 ( ) 02 ( ) 03 I l 01 f ) 02 ( 1 03 1 ) 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 t ) 01 1 ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 ( ) Ol f ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 f 1 03 ( ) 01 ( ) 02 ( ) 03 R CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/ARCA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE 301 CONTACT PERSONPN HE W/A CA CODE Y, DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT It R I 1 01 YES 1 1 02 NO NSC04-070185 910/18/851 PAGE 2