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i STATE ID NUMBER 000000356110OZ CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING i ) 05 GLASS LINING ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER F. ( ) 01 POLYETHLENE WRAP C 1 02 VINYL WRAPPING f l 03 CATHODIC PROTECTION (X) 04 UNKNOWN [ ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING= { ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH C J 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH [ ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( l 04 PRESSURE (X) 05 SUCTION f D 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION F(X) 01 VISUAL f ) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT F ( ) 06 GROUND WATER MONITORING WELLS C-X4 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 CASt# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED ( 1 01 ( ) 02 ( ➢ 03 ( 1 01 ( ) 02 ( ) 03 - ( ) 0l { 1 02 { } 03 ( ) 01 C ) 02 ( ) 03 ( J 01 ( ) 02 ( 1 03 ( ) 01 ( 1 02 ( ] 03 ( J 01 ( l 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 C ) 01 ( ) 02 ( ) 03 ( 1 01 ( 1 02 ( 1 03 I I 14 L L 1 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS FISCONTAINER 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. P RSON F ING I TU l p 0 ' W/APEA CODE - � FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID #i ( ) 07 YES i ) 02 NO PAGE 2 HSC04-070185 (10/18/85)