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STATE ID NUMBER 00000045931001 CONTAINER CONSTRUCTION E. ( 1 O1 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING (X1 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING= ( 3 01 DOUBLE—WALLED PIPE ( 3 02 CONCRETE—LINED TRENCH f ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 06 UNKNOWN ( 1 07—NONE VII LEAK DETECTION ( l 01 VISUAL ( J 0 STOCK INVENTORY ( ) 05 SENSOR INSTRUMENT t 1 06 GROUN ER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( 3 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CUPPENTLY RPEVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STC?ED STO=ED (X) 01 C 1 02 E 1 03 PAINT THINNER ( 1 01 ( ] 02 f 1 03 ( ) 01 ( 102 1113 1 11 f 11 1 1 1 1 1 ( ) 01 ( ) 02 ( 1 03 ( 1 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( 1 03 ( l 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 ( J 01 ( ) 02 t J 03 ( ) 01 ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS TS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UP)DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PR ONF LINO ( IGNATURE) PHONE W/AP.EA COPE, ir� FOR LOCAL AGENCY USE ONLY !/ ADMINISTRATING AGENCY 01S17- CITY CODE COUNTY CODE CONTACT ?FZSON PHONE W/AREA CODE DATEOF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # r' _J, ( ) 01 YES a ) 02 N( HSC04-070185 (10/18/85) PAGE 2