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STATE ID NUMBER 00000014943013 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING ( ) 07 UNLINED (X) OB UNKNOWN ( 1 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION f 1 04 UNKNOWN f ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: 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 f ) 06 UNKNOWN (.Al 07 NONE B. UNDERGROUND PIPING: ( l 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) f 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( 1 01 VISUAL Pd 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( ] 05 SENSOR INSTRUMENT ( 106 GROUND ER MONITORING WELLS Ob 07 PRESSURE TEST �)F)-09 NONE ( 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED l ) 01 ( ) 02 ( ) 03 ( 101 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 ( l 01 ( 1 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 f l Ol ( ) 02 ( ) 03 f 7 O1 ( ) 02 ( ) 03 f 7 01 ( 7 02 ( 7 03 l 7 01 [ ) 02 f ) 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, I5 TRUE AND CORRECT. PERSON FILING (SIGNATUP.E) PHONE W/ARE8'A CODE 209- 2 -FOR LOCAL LOCAL A NCY USE ONLY ADMINISTRATING A N Y CITY C00! COUNTY CODE ��1I�JOAQUIN LOCAL HEALTH DISTRICT 3 CONTACT VSONPHONE W/AREA CODE e Qr/S 20 9 - k_3 2- 5-Y DATE OF LAST INSPECTION IN COMPIIANC[ PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # f ) O1 YES f ) 02 NO HSC04-070185 (10/18/85) �� PAGE 2