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STATE ID NUMBER 00000014407001 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ] 05 GLASS LINING (X) 07 UNLINED t ) 08 UNKNOWN ( ) 09 OTHER.- F. THER:F. ( 1 01 POLYETHLENE WRAP f ] 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION f ) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT f ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH t 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( ) 01 VISUAL ( ) 02 STOCK INVENTORY [ ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS- (X) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CASA (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) STORED STORED ( 1 01 ( ) 02 ( 1 03 ( 1 01 ( ) 02 ( ) 03 t l 01 ( 1 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( l 01 ( 1 02 ( ) 03 ! ) 01 ( ) 02 ( ) 03 ( ] 01 ( 102 ( ) 03 ( 1 01 f ) 02 ( 1 03 +E CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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. SON FI} (SIGNATU E) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADM ISTRATSND AGENCY - ! CITY CODE COVNTY CODE c s CONTACT PERSON PHONE W/AREA CODE w ^ � ' CI� P +1 (- wop'h- IWrt (Y ^ 0A'I E_0i LASTT INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID A /i)' - p ( ) 01 YES ( ) 02 NO 1170185 (10/18/85) PAGE 2