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STATE ID NUMBER O0000057860001 CONTAINER CONSTRUCTION E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING [ l 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( l 01 POLYETHLEN€ WRAP ( l 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION (X) 04 UNKNOWN f l 05 NONE Il ( ) 06 TAR OR ASPHALT ( l 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE i ) 02 CONCRETE-LINED TRENCH [ ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH HA'l 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f 5 SUCTION ( ) 06 UNKNOWN f ) 07 NONE VII LEAK DETECTION ( ) O1 VISUAL ( 1 02 STOCK INVENTORY f J 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT f ) 06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST (X) 09 NONE ( l 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT P.ECUIREO TO COMPLETE THIS SECTION CUPPENTLY PREVIOUSLY DELETE CASH (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) TORED STORED I ) 01 ( ) 02 ( ) 03 I k l ( 1 01 ( ) 02 ( 1 03 - 1 01 ( ) 02 € 1 03 f 1 01 ( 1 02 ( ) 03 Lt 1 O1 f 1 02 i ) 03 01 ( 102 ( l 03 1101 ( 102 ( 1031IILI_.1_1_I _ i ] 01 ( ) 02 [ D 03 ( ) 01 ( ) 02 ( 1 03 i 01 1 ) 02 ( ) 03 j. CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS Lis CONTAINER LOCATED ON AN AGRICULTURAL FARMT ( ) 01 YES (X) 02 NO lhlE FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. U P ON W/AREA CODE FOR LOCAL AGENCY USE ONLY 1 =G1 ,VISTRkTING AGENCY "APPICIALCIATEP DE COUNTY CODE I CU,N'ACT PERSON NE W/ARE.A CODE _. �i t DATi OF LAST INSPECTION IN COMPLIANCE TRANSACTION DATE LOCAL PERMIT ID k ( I O1 YES ( ) 02 NO EISC04-170185 (10/18/85) PAGE 2