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STATE ID NUMBER 00000009845001 CONTAINER CONSTRUCTION 01 RUBBER LINED ( ) 02 ALKYD LINING [ 1 03 EPDXY LINING t ) 04 PHENOLIC LINING ( 7 05 GLASS LINING ( ] 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER 'F ( )(0) 06LTARHORNASWRAPPHALT (())009VOTHERWRAPPING ( ] 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) OS NONE VI PIPING ( 1 O1 DOUBLE-WALLEDFIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY A. ABOVEGROUND PIPING: (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE B. UNDERGROUND PIPING ) O1 DOUBLE-WALLED PIP ( E f l 02 CONCRETE-LINED TRENCH [ 1 03 GRAVITY 07 NONE (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( l 06 UNKNOWN ( 1 LL:( ):06 LEAK DETECTION VISUAUND(WA702 STOCKMONITINVENTORING R LS ((]I007 PRESSUREAPOR FTESTLLSX)( 05 09 NONEENSOR 10 OTHERTRUNT VI Ir CHEMICAL COMPOSITION OFMATERIALS ATISSORED s N UNDERGROUND CONTAINERS vn Yes DNOT REQUIRED D ETID CURRENTLY PREVIOUSLY DELETE CA S>< lIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STOPED STOPED ( 1 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( 7 01 ( 1 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) Ol [ ) 02 ( ) 03 ( ) 01 [ ) 02 ( ) 03 ( 7 01 ( ) 02 ( 1 03 ( ) 01 ( 1 02 ( 1 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. PHONE W/AREA CODE PERSON FILING t IGNATUR ) t A- FOR LOCAL AGENCY USE ONLY COUNTY CODE CITY CODE ADMINISTRATING AGENCY PHONE W/AREA CODE CONTACT PERSON DATE OF LAST INSPECTION IN COMPLIANCE PERMST APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID C f ) O1 YES ( ) 02 ND PAGE 2 HSC04-070185 (10/18/85)