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STATE IO NUMBER 00000001407004 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f l 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT f ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) 04 PRESSURE !4 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION 01 VISUAL l 02 STOCK INVENTORY [ 104 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( 1 06 GROUND TER MONITORING WELLS 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV•P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( ] 01 ( ) 02 ( ) 03 f 101 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 ( 1 Ol ( ) 02 ( ) 03 ( 101 ( ) 02 ( ) 03 t 1 01 ( ) 02 ( ) 03 l 1 Ol ( ) 02 ( ) 03 f 1 01 ( 102 ( 1 03 ( ) 01 ( 1 02 ( ) 03 ( ) 01 ( 1 02 ( 1 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO THIS FORM HAS E COMPLETE NOER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PER ON FIL O (S LTTJJRE1 PHONE W/AREA CODE L OR LOCAL AGENCY USE ONLY AOMI NI STRA ING AOlN CITY CODE COUNTY CODE r CONTACT P SON PHO E W/ REA CODE DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID Y l ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) \ \ , PAGE 2