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STATE ID NUMBER 00000061457001 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED f ) 02 ALKYD LINING ( ] 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING f ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X1 04 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING• ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) l ) 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 (X) 05 SUCTION ( 1 06 UNKNOWN f ) 07 NONE VII LEAK DETECTION f 1 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STCRED STORED ( ) Ol ( ) 02 ( ) 03 ( ) al ( ) 02 ( ) 03 ( 1 Ol ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( ) Ol ( 1 02 ( 1 03 ( 1 Ol ( ) 02 ( 1 03 ( 1 01 ( ) 02 ( ) 03 f 1 Ol ( ) 02 ( ) 03 ( ) Ol ( 1 02 ( ) 03 ( I 01 ( ) 02 ( ) 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 BEEN COMPL ED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FI G S NAT ) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY AOMI N/STRATINO AOE NCY CITY C2ODE COUNTY CODE CONT T PERSON P NE W/ RE(A�C�ODE (YO DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL GATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YfS f ) 02 NO HSC04-070185 (10/18/85) PAGE 2 yw