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('- . • STATE IO NUMBER 00000020256001 CONTAINER CONSTRUCTION E. 1 ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( 1 05 GLASS LINING ) 07 UNLINED (X) 08 UNKNOWN 1 ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP 1 102 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN l 1 05 NONE ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ( 1 05 SUCTION 1 1 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINEO TRENCH ( 1 03 GRAVITY (CHECK APPROPRIATE SOX(ES) (X) 04 PRESSURE ( 1 05 SUCTION l l 06 UNKNOWN f 1 07 NONE VII LEAK DETECTION 1 ) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST ( 1 09 NONE ( ) 30 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 1 ) 02 1 1 03 ( ) 01 f 1 02 ( ) 03 ( ) 01 1 1 02 ( 1 03 ( ) 01 ( 1 02 ( ) 03 1 1 01 ( 1 02 ( ) 03 I 1 01 ( ) 02 ( ) 03 l l 01 ( ) 02 ( 1 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 1 ) 01 ( ) 02 ( ) 03 I I I l l 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. PSON FILING (SIGN4TUPE1 PMONE W'APEA CODE - FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENDY CITY_ CODECOU-TY ' CODE - CONTACT PEPSCN PH HE W/APE4 CODE ' 44 DATrl-LIST NSPECTION IN COMPLIAND 11PERMIT APPROVAL DATE TICN DATE KCAL PERMIT ID # f f 01 YES ( 102 NO HSC04-070185 (10/18/85) PAGE 2 (