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STATE ID NUMBER 00000063124002 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1. 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( J 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE i ) 02 CONCRETE-LINED TRENCH f 7 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: f 7 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) OO 0� 4 PRESSURE i 1 05 SUCTION ( ] 06 UNKNOWN i 7 07 NONE VII LEAK DETECTION ( 7 01 VISUAL (X) 02 STOCK INVENTORY f l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS l 1 07 P TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STOPED ( 7 01 ( 1 02 f ) 03 ( ) 01 ( 7 02 ( ) 03 f ) O1 ( 1 02 ( ) 03 ( 1 01 ( 1 02 ( ) 03 ( 1 Ol ( ) 02 ( ) 03 l 1 01 l ) O2 ( ) 03 1 ) O1 l ) 02 ( ) 03 ( ) al f ) 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 ( 1 Ol ( l 02 ( ) 03 R 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 FZLIN fSI NATUR ) PXO W/ EA C�00z8(y7 71G FOR LOCAL AGENCY LitE ONLY ADMINIST , AOE Y w/( /�� / � CITY CODE COVNS f DE CONTACT E ON `/�GN•M/ J T/!9 IV PHONE W/A A CODE J DATE ;/j AST ;;PECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # 3 G 01 YES ) 02 NO HSC04-070185 (10/18/85) / PAGE 2