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CONTAINER CONSTRUCTION _ STATE ID NUMBER 00000016476001 EE R LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 7 05 GLASS LINING LINED ( ) O8 UNKNOWN ( 7 09 OTHER:HLENE WRAP ( 7 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH f ) .03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 7 04 PRESSURE f ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( 7 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) O1 VISUAL fX] 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ` ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE 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) STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) f ) 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( ) Ol l 7 02 ! ) 03 ! ) Ol f ) 02 ( ) 03 l ) Ol ( ) 02 ( ) 03 ( 7 01 ( 7 02 f ) 03 ( ) O1 l 1 02 ( 7 03 f ) Ol f ) 02 ( 7 03 ( ) Ol ( ) 02 f 7 03 ( ) Ol f 7 02 f ) 03 !F CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? [ 1 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. PEP.SON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( 1 02 NO 4SC04-070185 (10/18/85) PAGE 2