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Now vo STATE ID NUMBER 00000034786002 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (a(l' 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( ] 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN Ck+ 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE I>�'O5 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( ) 01 VISUAL ( l 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( l 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST (x-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) STOPED STOPED f ) O1 f ) 02 ( ) 03 f ) Ol ( 1 02 ( ) 03 ( ) Ol ( ) 02 ( 103 f ) 01 ( 1 02 ( ) 03 ( 1 01 ( ) 02 1 1 03 ( 101 ( 1 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 02 f 1 03 1 1 Ol f ) 02 f 1 03 ( 1 O1 ( ) 02 f ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( 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 AD NISTRT NO AGENNCYYn-1 (�15 1 CITY CODE COUNTY CODE CONTACT PCRSON J 17+ PHONE W/AREA CODE P_7:,f,LuraCL rd._�_ )-d 9- 3 6 DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE . TRANSACTION DATE LOCAL PERMIT ID # ( ) O1 YES ) 02 NO HSC04-070185 (10/18/85) �evr�Jr� PAGE 2