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STATE ID NUMBER 00000042134010 CONTAINER CONSTRUCTION ( ) 01 RUBBER LINED t ) 02 ALKYD LINING (X) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( l 05 GLASS LINING t ) 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER- ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: 'I PIPING (. ABOVEGROUND PIPING: i 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY [CHECK APPROPRIATE SOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN t 1 07 NONE f. UNDERGROUND PIPING- { l 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION t l 06 UNKNOWN ( ) 07 NONE 'II LEAK DETECTION (X) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( 1 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST i ) 09 NONE ( l 10 OTHER- FIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECYED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION .URPENTLY PPE`:ICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NOME) STCRED STOPED tXi 01 ( ) 02 ( 1 03 IIJ3I3I0I2I017I � I I I I XYLENE, ALL ISOMERS ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 i l 03 t ) 01 ( ) 02 ( ) 03 ( ) 01 ( 1 02 ( 1 03 ( 1 01 ( ) 02 ( 1 03 ( l 01 ( ) 02 ( ) 03 ( ) 01 ( l 02 ( 1 03 f ) 01 f ) 02 ( ) 03 ( 1 01 ( l 02 ( ) 03 I I I CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED CH AN AGRICULTURAL FARM? ( l 01 YES (X) 02 NO HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. ;EPSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AuENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE ❑.ATE OP LAST INSPECTION IN COMPLIANCE FE.7r""IT APPROVAL DATE TRANSACTION DATE 64CAL PERMIT ID tt ( l 41 YES ( ) 42 NQ PAGE 2 iSC04-070185 (10/18/85)