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STATE ID NUMBER 0000001374002 CONTAINER CONSTRUCTION E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING [ 1 03 EPDXY LINING ( l 04 PHENOLIC LINING [ 1 05 GLASS LINING [ ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. { ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN C ) 05 NONE ( ) 06 TAP, OR ASPHALT ( ) 09 OTHER.- VI THER:VI PIPING A ABOVEGROUND PIPING: ( l 01 DOUBLE-WALLED PIPE ( 1 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 t ) 02 CONCRETE-LINED TRENCH C ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE [ 1 05 SUCTION ( l 06 UNKNOWN ( l 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT [ ) 06 GROUND WATER MONITORING WELLS i ] 07 PRESSURE TEST E ) 09 NONE i 1 10 OTHER: L VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO ::V-F YOU A;;E NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STGREO STORED --- ( ) 01 { 1 02 ( ) 03 - - ( 1 01 f ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 t ) Oi [ ) 02 { ) 03 [ ) 01 { ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 ( ) 01 ( l 02 ( ) 03 ( ) 01 E l 02 { ) 03 ( ) 01 ( ) 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. PERSON I ING (ST GNATURE ) P O��W�A CODE FOR LOCAL AGENCY USE ONLY ADMT_NISTPATYNG AGENCY CITY CODE COUNTY CODE PHO E W AREA CODE CCNTACTEPSON M-6-mg ,Gtr DATE OF LAST INSPECTION IN COMPLIANCE PEP.MIT APPROVAL DATE TP.ANSACTION DATE LOCAL PERMIT ID tt 1 1 01 YES ( f 02 NO PANE 2 HSC04-070185 (Iflt18f85)