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STATE ID NUMBER 00000021421001 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( l 02 ALKYD LINING 1 ) 03 EPDXY LINING l ) 04 PHENOLIC LINING ( l 05 GLASS LINING ( 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( ] 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ] 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 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 f ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (]4. 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS [ 7 05 SENSOR INSTRUMENT f ) 06 GROUND-WATER MONITORING WELLS f l 07 PRESSURE TEST fi44 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS /F YOU CHECKED YES TO IV-F 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 1 01 ( ) 02 ( ) 03 ( ) Ol ( 7 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 f ) Ol ( 1 02 ( ) 03 ( 7 Ol ( 1 02 ( ) 03 ( ) O1 ( 102 ( ) 03 ( ) 01 ( 1 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 * 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/AREA CODE FOR LOCAL AGENCY USE ONLY AC MI NISTRA TING AGENCYCITY COD[ COUNTY CODE CONTACT ERSON PH HE W/AREA CODE DATE OF LAST INSPECTIONIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # ( 1 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2