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r 0 STATE ID NUMBER 00000031249001 CONTAINER CONSTRUCTION E. C ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( } 04 PHENOLIC LINING ( 105 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN t ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP f l 02 VINYL WRAPPING ( } 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPI),G: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ] 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( 1 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION f ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS C } 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU C"ECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CA$# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STOPED ( ) 01 ( 1 02 ( ) 03 ( 1 01 ( 1 02 ( 1 03 i 1 01 ( 1 02 ( 1 03 f 1 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 { l 01 ( 1 02 4 1 03 01 ( ) 02 ( ) 03 S 1 01 ( 1 02 ( 1 03 f 1 01 ( 1 02 ( 1 03 { 1 01 ( 1 02 ( } 03 * CHECK STATE 'BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? l } 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 FILING (SIGNATURE) P NE W/.APEA CODE ov FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CO3E CONTACT PERSON PHONE W/AREA CODE B 2©q-93,/ DATE OF LAT $P$PECTION IN COMPLIANCE PERMIT .APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # 01 YES ( ) 02 NO HSC04r-070185 (10/18/85) PAGE 2