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rr + 0 STATE IO NUMBER 0000000;741001 CONTAINER CONSTRUCTION E. f 3 01 RUBBER LINED ( ) 02 ALKYD LINING i l 03 EPDXY LINING ( 3 04 PHENOLIC LINING ( D 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( 3 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING [ ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE [ l 06 TAR OR ASPHALT ( l 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE C ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE i ) 05 SUCTION ( 106 UNKNOWN C ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE E ) 05 SUCTION [ ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( D 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F 'Y'OU APE NOT REGUIRED TO COMPLETE THIS SECTION CUPRENTLY PRE'C'IOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL ,vawE STC-ED STORED 01 ( ) 02, ( ) 03 i ) 01 i l 02 ( ) 03 ( ) 01 ( 1 02 f l 03 ( D 01 ( D 02 ( 1 03 i ) 01 [ ) 02 ( ) 03 ( D 01 ( l 02 ( l 03 ( D 01 ( ) 02 ( ) 03 ( ) 01 ( 3 02 ( ) 03 C ) 01 ( 1 02 ( 1 03 ( ! 01 ( l 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS !IS CONTAINER LOCATED ON AN AGRICULTURAL FARM' ( 1 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. PERSON FILI�3 (SZON4TURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ACMINISTPATING AGENCY CITY CODE COUNTY CODE rj Z c�C �, A 4�777 CONTACT PERSON PHONE W/.AREA CODE DATE OF LAST INSPECTION/ IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL P_RfIT ID _,/ ( ) 01 YES ( ) 02 NO '04-070185 (10/18/85) PAGE 2