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"bow 1140 STATE IO NUMBER 00000024099003 CONTAINER CONSTRUCTION E. l 101 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( l 04 PHENOLIC LINING ( 1 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE f l 05 SUCTION f 1 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION [ 1 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( 1 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( 1 09 NONE ( 1 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( 1 01 ( ) 02 ( 1 03 ( 1 01 ( ) 02 ( 1 03 ( ) 01 ( 1 02 ( ) 03 f 1 O1 f ) 02 ( ) 03 ( l 01 f 1 02 ( 1 03 ( 1 Ol ( ) 02 ( 1 03 ( 1 01 ( 1 02 ( 1 03 ( 1 Ol ( 1 02 ( 1 03 f 1 01 ( 1 02 ( 1 03 ( ) 01 ( ) 02 ( 1 03 ■ 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. PERSON FILING (SIGNATURE) - PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/ARCA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( 1 01 YES ( 1 02 NO HSC04-070185 (10/18/85) PAGE 2