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• • STATE ID NUMBER 00000009875002 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING C ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 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 ( 1 05 SUCTION f ) 06 UNKNOWN ( 1 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION f l 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS [ ) 05 SENSOR INSTRUMENT f ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST f ) 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 CASA (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STOPED STORED ( 1 01 f l 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f ) 01 ( 1 02 ( ) 03 f 1 01 ( ) 02 ( ) 03 ( ) 01 ( l 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( I 01 f 1 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 • 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 C LE ED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON F Z A E) PHONE W/AR A CODE FOR LOCAL AGENCY USE ONLY 2 ACHZN TP.ATIM1%.AO°NCV CITY CODE COUNTY CODE {�1 JD (nlN -zN CONTACT PERSON PHONE W/AAO CODE ^ r � _ - ss DATE OF LA T INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 4 01 YES ( ) 02 NO PAGE 2 HSC04-070185 (10/18/85)