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• • STATE ID NUMBER 00000054350002 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING ( ) 07 UNLINED (X1 08 UNKNOWN ( ) 09 OTHER: F. ( 1 O1 POLYETHLENE WRAP t ) 02 VINYL WRAPPING ( 7 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( 7 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 7 03 GRAVITY (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 7 07 NONE VII LEAK DETECTION ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS l ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STOPED STOPED ( ) 01 ( l 02 f 7 03 ( 101 ( 1 02 ( 7 03 f 7 01 ( ) 02 ( ) 03 ( 7 01 [ 1 02 f 1 03 ( 1 01 ( ) 02 ( ) 03 ( 7 Ol ( 1 02 ( ) 03 ( ) 01 ( ) 02 f 1 03 ( ) 01 [ ] 02 ( ) 03 ( 7 01 ( 1 02 ( ) 03 ( 7 Ol f 1 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 FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATIN3 AGENCY CITY CODE COUNTY CODE CONTACT PERSON HDATE AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVALNSACTION DATE LOCAL PERMIT ID S f ) Ol YES ( ) 02 NO PAGE 2 HSC04-070185 (10/18/85)