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. STAfE ID NUMBER 00000016769003 CONTAINER CONSTRUCTION 01 RUBBER LINED 1 ) 02 ALKYO LINING [ 1 03 EPDXY LINING 1 04 PHENOLIC LINING 1 ) 05 GLASS LINING ( 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING l 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER) VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY �'H� (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( 1 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE /�� i VII LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CH'-CMED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE CCMMERCIAL NAME) STOPED STOREC (X) 01 ( 1 02 ( ) 03 PESTICIDES (X) 01 ( 1 02 ( ) 03 FERTILIZER RINSE WATER ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( 1 01 ( 1 02 ( 1 03 f ) 01 ( 1 02 f ] 03 ( ) 01 ( 1 02 ( 1 03 ( ) 01 ( l 02 ( ) 03 ( 1 01 f ) 02 f ) 03 ■ 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 F LING (SIG ' PHONE AREA C DE () 3 rL{d.A1,QcY FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNT)' CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LCCAL PERMIT IO # ( > 01 YES f ) 02 NO PAGE 2 HSC04-070185 (10/18/85)