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.� STATE ID NUMBER 00000007438001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 103 EPDXY LINING f ) 04 PHENOLIC LINING f 1 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE S. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) 04 PRESSURE ( 05 SU N f l 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION f ) 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS l 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS VeJ 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 CASII (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED f 1 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 ( ) 01 ( ) 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 COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON ILING ( I NATUR J PHONE W/AREA CODE 2 $Ti FOR LOCAL AGENCY USE ONLY 40MT ISTFAT�O AGENCY � fl / j CITY CODE COUNTY C.3`/ODE C_ZI�N,;�TlCGf7 ON A�D��r PHOS W REA CODE �"o� �»— s;'5z59 GATE 0LAS I SPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE PERMIT ID E /Z�� ( ) 01 YES ( ) 02 NO LOCAL HSC04-070185 (10/18/85) PAGE 2 ��