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STATE ID NUMBER 00000058940003 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYO LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING ( l 07 UNLINED ( ) 08 UNKNOWN ( l 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( l 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK. APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( l 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( l 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YCU CHECKED YES TO !V-F YOU APE NOT REQUIPED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF kNCWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STO:ED STC''+ED ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( 1 02 ( l 03 ( 1 01 ( l 02 ( ) 03 ( ) 01 f ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 ( l 02 ( ) 03 ( l 01 ( 1 02 ( l 03 ( ) 01 ( l 02 ( 1 03 ( l 01 ( ) 02 ( l 03 ( l 01 ( l 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES ( ) 02 NO CHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/APE.A CODE -FOR LOCAL AGENCY USE ONLY A.DMINISTPATINO AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AP.EA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO =3C04-070185 (10/18/85) PAGE 2