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�. .. 'y. STATE ID NUMBER 00000030256006 CONTAINER CONSTRUCTION E. i ) 01 RUBBER LINED ( ) 02 ALKYO LINING f 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN f ) 05 NONE f ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 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 ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) to-04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN (.XJ-07 NONE VII LEAK DETECTION t'XY 01 VISUAL (%) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ] 05 SENSOR INSTRUMENT I ( l 06 GROUND WATER MONITORING WELLS yC) 07 PRESSURE TEST ( ] 09 NONE f 1 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 CASP (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STOPED STORED ( ) 01 ( ) 02 ( 1 03 ( 1 01 ( ) 02 ( 1 03 f ) 01 ( ) 02 ( / 03 ( ) 01 ( ) 02 ( 1 03 ( 1 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( 1 03 ( ) Ol ( ) 02 ( 1 03 ( ) Ol ( ) 02 ( ) 03 ( ) Ol ( ) 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 FILING (SIGNATURE ) PHONE W/AREA CODE 2pq-9/ffs FOR LOCAL AGENCY USE ONLY ADMINZSTRATI NO AGENCYCITY CODE COUNTY cone CONTACT EPSON PHO E W/AREA CODE 04 6 6 DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID u ( ) 01 YES C ) 02 NO HSC04-070185 (10/18/85) PAGE 2