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STATE ID NUi'1BER 00000011249402 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION i 1 04 UNKNOWN (X) 05 NONE C l 06 TAR OR ASPHALT ( l 09 OTHER: VI PIPING A. AEOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07NONE B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION f ) 01 VISUAL (X) 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 CHECF:EO ',.ES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION C^^_pPcv,NTLY PPEVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) ITOPEn STCPED ( l 01 ( 1 02 ( 1 03 ( l 01 ( ) 02 ( ) 03 ( 1 01 ( l 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 { 1 01 ( ) 02 ( 1 03 ( l 01 ( ) 02 ( ) 03 f ) 01 ( 1 02 ( 1 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 [ 1 02 ( 1 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 FT IN^ (SIGMA URE,,), / PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINIST ATIN3 AGE !,I�! , CITY CODE COUNTY CODE //v cog CONTACT PERSON PHONE W/AREA CODE ��/) r� l e e ,_-7j f (its DATE OF LASTECTION IN COMPLIANCE PERMIT APPROVAL DATE .ANSACTION DATE LOCAL PERMIT 10 # C� 1 )COMPLIANCE01 YES ( 7 02 NO TP HSC04-070185 (10/18/85) PAGE 2 � i