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CONTAINER CONSTRUCTION STATE ID NUMBER 00000009692001 E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: F. ( ) 03 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ] 04 UNKNOWN ( ) OS NONE (X) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE SOX(ES) [ 1 04 PRESSURE SUCTION ( ) 06 UNKNOWN [ ) 07 NONE 8. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X.) 05 SUCTION ( 1 06 UNKNOWN ( T 07 NONE VII LEAK DETECTION f ) 01 VISUAL W 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 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) STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) ( 1 02 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( J 01 f 1 02 f ) 03 ( ) 01 ( 1 02 ( 7 03 ( l Ol ( 7 02 ( ) 03 01 ( 7 02 ( 1 03 ( ] Ol ( ) 02 ( ) 03 ( 7 Ol ( ) 02 ( ] 03 ( ) O1 ( ) 02 f 1 03 f ) 01 ( 7 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 UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PER a, O ( NATUR ) PHON W�q CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING ASENCY IST S�� CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE 0 LAy INSTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE -3 / �j— � U V ( ) O1 YES ( ) 02 NOLOCAL PERMIT ID # SC04-070183 (10/18/85) PAGE 2