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. STATE ID NUMBER 00000016769002 CONTAINER CONSTRUCTION . f 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING l 1 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN f 109 OTHER: 1 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT ( 109 OTHER: I PIPING . ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN 1 ) 07 NONE `YC 4111x' II LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: III CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION UPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STOPED (X) 01 ( ) 02 ( ) 03 PESTICIDES (X) 01 ( ) 02 1 1 03 I I I I I I I I I I I I FERTILIZER RINSE WATER ( 1 01 ( 1 02 ( 1 03 1 ) 01 ( 1 02 ( 1 03 ( 1 01 ( 1 02 ( ) 03 ( 1 Ol ( l 02 ( ) 03 f ) O1 ( 1 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 I l 01 O 02 1 1 03 O O1 O 02 ( 1 03 R CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO QS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. ti+ E PSC / PHONE W/AREA CODE Ala 3'�% Yrd b7 OR LOCAL AGENCY USE ONLY OMINISTPATING AGENCY CITY CODE - COUNTY CODE CNTACT PERSON PHONE W/ARCA CODE ATE OF LAST INSPECTION INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # ( ) O1 YES ( 1 02 NO C04-070185 (10/18/85) PAGE 2