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I � � CONTAI ER CONSTRUCTION STATE ID NUMBER 00000038443003 E. ( 1 01 RUBS R LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 07 U LINED (X) 08 UNKNOWN f ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 05 GLASS LINING (X) 06 TA OR ASPHALT ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f 1 04 UNKNOWN ( ) 05 NONE ( ) 09 OTHER: VI PIPING A• ABOVEGROUND IPING: (CHECK APppO{ IATE BOX(ES) ( ) O1 DOUBLE-WALLED PIPE f ) 02 CONCRETE LINED TRENCH ( ) 03 GRAVITY ( ) 04 PRESSURE f ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE B. UND FRGROUNO P PING: f ) O1 DOUBLE-WALLED LLED PIPE (CHECK APpROP IATE BOX(ES1 ( ) 04 HE ( ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY OS SUCTION f 1 Ob UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL ( 1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND ATER MONITORING WELLS ( ) 07 PRESSURE TEST f ) 09 NONE f 1 10 OTHER: VIII CHEMICAL COMPOSITION OF IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO C MPLETE THIS SECTION TERIALS STORED IN UNDERGROUND CONTAINERS CURRENTLY PREVIOUSLY DELETE CA Slt (IF KNOWN) STORED STORE CHEMICAL (DO NOT USE COMMERCIAL NAME) ( ) Ol ( ) 02 ( 1 03 ( ) Ol ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 ( J 01 f ) 02 ( ) 03 ( l Ol ( ) 02 ( ) 03 ( 7 01 [ 1 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 CHECK STATE BOAR CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO IS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. EPSON ING -NSIGNATJRE7 PHONE W/AREA CODE - 7Z3 - y8a8 OR CAL AGENCY USE ONLY )MINISTRATING AGENCY 5 /IST- CITY CODE jof(i COUNTY CODE �N TACT PERSON E, TOS PHONE W/AR Co TE OF LAST INSP CTI IN COMPLIANCE G71AN OQ' PERMIT APPROVAL DATE TRANSACTION DATE ( ) O1 YES ( l 02 NO LOCAL PCRMIT ID b D4-070185 (10/18/8 PAGE 2