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a r i r STATE ID NUMBER 00000011073001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( D 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT t ) 09 OTHER:_— — VI PIPING I A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( D 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLEDYPE ( ) 02 CONCRETE—LINED TRENCH t ) 03 GRAVITY (CHECK APPROPRIATE BOXES) t 1 04 PRESSURE ( 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( D 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF TOU CHECKED t'ES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION CUPPENTLY PPEV:CVSLY DELETE CAS8 (IF 6:NCWN) CHEMICAL (DO NOT USE COMMEPCIAL NAME ) STC:)ED S7CPE^u ( l 01 ( 1 02 O 03 ( D 01 l ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 ! ( D 01 ( ) 02 ( 1 03 ( ) 01 ( 1 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 i ( ) 01 ( ) 02 ( D 03 1101 ( D02 ( 103lllilllilllll ( ) 01 t ) 02 ( 1 03 ( 1 01 ( 1 02 t ) 03 I * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( D 01 YES (X) 02 NO TLHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. �1 PEPSCN FILING (SIGNATUPE ) PHONE W/AP.EA CODE FOR LOCAL AGENCY USE ONLY ADMINISTR.A7ING AGENCY CITY CODE COUNTY CODE CONTACT PEPSON PHONE W/AREA CCOE D.-.TE OF LAST INSPECTION IN COMPLIANCE PEPMIT APPROVAL DATE TPANSACTION DATE LOCAL PERMIT ID 4 — ------ _ ( ) 01 'r E S t ) 02 N� --�---- HSC04-070185 (10/18/85) PAGE 2