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aSTATE ID NUMBER 00000036877001 CONTAINER CONSTRUCTION E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER F. (. 1 01 POLYETHLENE WRAP I ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER- VI PIPING A. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN 0e) 07 NONE B. UNDERGROUND PIPING: ( ) O� DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) a 04 PRESSURE ( ) 05 SUCTION Oe,06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ,jdS� 01 VISUAL 00 02 STOCK INVENTORY [ ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ] 06 GROUND-= ER MONITORING WELLS OC) 07 PRESSURE TEST ( ) 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 (00 NOT USE COMMERCIAL NAME) STOPEO STOPED f l 01 ( ) 02 ( ) 03 f l 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( ) 01 f l 02 ( 103 ( ) 01 ( ) 02 ( 1 03 ( ) O1 f ) 02 ( ) 03 ( ) 01 f ) 02 ( ) 03 ( i 01 ( ) 02 ( ) 03 ( ) 01 f ) 02 ( ) 03 ( ) 01 f ) 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 ADMINISTRATINGAGENCY CITY CODE COUNTY CODE l I � ) CONTACT PARRSC. PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # Ct/, ,ge01 YY.ES ( 1 02 NO 8��/P f ) PAGE 2 HSC04-07//0185✓� (010/18/85) "/