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STATE ID NUMBER 00000010265001 CONTAINER CONSTRUCTIONE. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHE14OLIC LINING l ) 05 GLASS LINING [ ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER= F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE 4 ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. HERAPPRPRI ( )ID0LEO 11CRETRENCH ( 3 GRAVITY (CCKAPPROPRIATE BOX(ES) ( 0PRESSURE05 SUCTION ( ) 06UNKNOWN ( ) 07NONE B. UNDERGROUND PIPING= ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( l 04 PRESSURE (X) 05 SUCTION l ] 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION .(X) O1 VI�( ) OCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT) 06 NITORING WELLS [ l 07 PRESSURE TEST [ 1 09 NONE ( ) 10 OTHER VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS Ir YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CASH (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) I STORED STORED E ) 01 ( 1 02 ( ) 03 ( 3 01 ( ) 02 ( ) 03 ( ) 01 [ ) 02 ( ) 03 E( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ] 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 t ) 02 ( l 03 ( ) 01 t ) 02 ( ) 03 t ) 01 ( ) 02 [ ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 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. __J _ PERSON FILI S NAT .E ) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY COUNTY CODE ADMINISTRATING .AGENCY CITY CODE PHONE W/AREA CODE CONTACT PERSON DATE OF LAST INSP CTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID k ( ) 01 YES ( l 02 NO PAGE 2 HSC04-070185 (10/18/85)