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STATE ID NUMBER CONTAINER CONSTRUCTION J IE. 1 1 01 RUL'BEk LINED ( 1 02 ALKYD LINING ( 1 U3 EPDXY LINING 1 ) 04 PHENOLIC LINING l ) OS GLASS LINING (k 07 UNLINED I 1 08 U11KNOWN ( 1 09 OTHER: 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION l 1 04 UNKNOWN �) 05 NONE I ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING r--- 4. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE IS. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CCNCPETE-LINED TRENCH ( ) 03 GRAVITY --ICIiECK. APPROPRIATE BOX(ES) I PRESSURE f ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (�02 STOCK. INVENTORY - ( ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT/� / L 1 1 06 GROUND WATER MONITORING WELLS f ) 07 'PPESSURE TEST ( ) 09 NONE (x 10 OTHER: /I /�s 46L. L_ VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS 7_�-- IF YOU CHECKED YES TO I\'-F YOU ARE NOT RERUIP.CD TO COMPLETE THIS SECTION CVRPEKTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STORED r O 01 O 02 ( 113 1 1 1 1 1 1 1 L ) Ol 11 02 O 03 I ( 1Ol II02 1103IIIIIIIIIIIII LI 1-Dl ( 02 t ) C ) 01 ( l oz l ) 03 L-LLLLI ( I I I I I 111 ---- --------- I ( IIIIIIIIIIII ( 1 01 ( 1 02 l l 03 '_t ) 01 f ) 02 11 03 f l Ol f ) 02 l ) 03 I u� Y c , IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 YES( ) Ol YES ( 2 N0 I i THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY ZOE PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PE N FILING (SIGNATURE) pN ql HE W/A A CCD[ �� U �L l FOR LOCAL AGENCY USE ONLY IADMI HISTRATI '0 AGENCY CITY_ C E COUNTY CODE 3 I O NIACT EPSON PHO E W/ARD CO (DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE II�LOCAL PERMIT ID # O1 YES f 1 0: NO I ---- HSC04-070185 J PAGE 2