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STATE ID NUMBER 00000057023003 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING [ 7 04 PHENOLIC LINING [ ) 05 GLASS LINING (XI 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. f ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING l ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( ) 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 ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( 1 O1 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS l ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT RECUIRED TO COMPLETE THIS SECTION CUPPENTLY PREVIOUSLY DELETE CA$# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STCRED STOPED ( ) 01 ( ) 02 ( ) 03 ( ) Ol ( l 02 ( ) 03 ( ) OS ( ) 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 .._ f 1 01 ( 7 02 ( ) 03 _ ( 1 Ol ( ) 02 ( ) 03 .. ( ) 01 ( ] 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 ( ) Ol ( l 02 ( 103 .- ( ) 01 ( 1 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. PERSON FILING (SIGNATURE) PHONE W/AREA CO FOR LOCAL AGENCY USE ONLY �L/VDE ADMINISTRATING AGEtTIONIN CITY CODE COUNTY CODE ot�4L f �'( t+ �I S7 CONTACT PERSON PHONE W/AREA CODE Cn� r�/2 20 - 8-d666 OXTE OF LAST INSPEPLIANCE PERMIT APPROVAL DATE TRANSACTION DATELOCAL PERMIT IO 1tl YES ( ) 02 NO PAGE 2 iSC04-070185 (10/18/85)