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Now Y STATE ID NUMBER 00000054749009 CONTAINER CONSTRUCTION E. t ) 01 RUBBER LINED 1 1 02 ALKYD LINING f ) 03 EPDXY LINING f 1 04 PHENOLIC LINING (X) 05 GLASS LINING ( ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION f ! 04 UNKNOWN (X) 05 NONE ( 1 06 TAR OR ASPHALT f 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH l 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION 1X1 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN l ] 07 NONE VII LEAK DETECTION ( ) O1 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ] 07 PRESSURE TEST (X) 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 CURPENTLY PREVIOUSLY DELETE CASE (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOPED 1X1 01 ( 1 02 O 03 11101014131512141 CALCIUM CHLORIDE (X) 01 1 1 02 ( ) 03 171717151111131 SODIUM CHROMATE ( 1 01 f 1 02 ( 103 ( ) Ol f 1 02 ( ) 03 ( ) Ol f 1 02 ( l 03 ( ) 01 ( 1 02 ( l 03 ( I 01 ( ) 02 f 1 03 ( ) 01 ( ) 02 ( ) 03 f ) Ol 1 ) 02 ( ) 03 ( ) Ol f 1 02 f 1 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES (X) 02 NO PHIS FORM HAS BEEN COMPLETED UNDIV, THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATUP PHONE W/APEA CODE FOR LOCAL AGENCY USE NLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID k ( ) O1 YES f 1 02 NO ISC04-070185 (10/18/85) PAGE 2