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�.. "' STATE ID NUMBER 00000054749009 CONTAINER CONSTRUCTION 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING f l 04 PHENOLIC LINING (X1 05 GLASS LINING ( ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES1 ( ) 04 PRESSURE l 1 05 SUCTION ( ! 06 UNKNOWN l ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL t ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT f ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TD IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED (X) O1 ( ) 02 ( ) 03 1 01014131-512141 CALCIUM CHLORIDE (X) 01 ( ) 02 ( ) 03 171717151111131 SODIUM CHROMATE ( 1 01 ( ) 02 ( ) 03 f ) al ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 I 1 Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 f 1 01 ( ) 02 l 1 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 UNOTk THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATUR PHONE W/AREA CODE FOR LOCAL AGENCY USE NLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/ARlA COD! DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DAT[ LOCAL PERMIT ID # ( ) O1 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2