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STATE ID NUMBER 00000020256003 CONTAINER CONSTRUCTION 7. ER LINED �) 02 KYD LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING 1 ) 05 GLASS LINING NlINEO ( OWN l 109 OTHER (��7 ' ( l O1 POLYETHLENEWRAP f ) 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION (Xl 04 UNKNOWN 1 1 05 NONE ( 1 06 TAR OR ASPHALT ( 109 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 ( ) 07 NONE B. UNDERGROUND PIPING* ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( 1 05 STICTION 1 ) 06 UNKNOWN l 1 07 NONE VII LEAK DETECTION ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IP YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED ( 1 01 ( 1 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 ( 1 01 ( 1 02 ( ) 03 ( ) 01 ( 102 ( ) 03 f 1 Ol ( 1 02 ( 1 03 ( ) 01 ( 1 02 ( ) 03 l ) 01 ( ) 02 ( ) 03 ( 1 01 ( 102 ( ) 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS ISCONTAINER LOCATED�ANICULTURALFARM? f OO1 YES �(X) 02 THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATUPE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY11 COUNTY CODE S CONTACT PERSON PHONE W/AR A CODE l DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID R ( ) 01 'IES ( 1 02 NO HSC04-070185 (10/18/85) PAGE 2