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STATE ID NUMBER 00000054432003 CONTAINER CONSTRUCTION 01 RUBBER LINED ( 1 02 ALKYD LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 7 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: Ff ( 1 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE (X) 06 TAR OR ASPHALT ( ) 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 (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING• ( ) 01 DOUBLE-MALLEO PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ESI ( 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN l ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ] 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRE55URE TEST (X) 09 NONE ( ) 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 (DO NOT USE COMMERCIAL NAME) STORED STORED [ 1 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( 1 03 ( l 01 ( ) 02 ( ) 03 ( l 01 ( 1 02 ( ) 03 ( 1 al 1 1 02 ( ) 03 ( 1 Ol f 1 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 1 ) 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 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 U TA PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FIIING (SIGNATURE) PHON W_/�A\R EA @OO F. ' 1 '—�3 FOR LOCAL AGENCY USE Y v ql J LJI It ADMINISTRATING AGENCY I ( CITY CO E COUNTY CODE CCNTA CT lRSON `J•.`I-'v- 3PHONE W/ARE CODE14 (,4✓^t 3 II DATE Of LAST SPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTIONf_DIIATE LOCAL PERMIT ID # ( ) O1 YES ( ) 02 NO HSC04-070185 110/18/851 PAGE 2 `/