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j STATE ID NUMBER ;00000000725003 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ' 3 EPDXY LININGt ) 04 PHENOLIC LINING ( ) 05 GLASS LINING "" "' " '""'"� ( ) 08 UNKNOWN ( ) O HER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING C } 03 CATHODIC PROTECTION t ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND :PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 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 X(ES) (X) 04 PRESSURE ( 1 05 SUCTION C ) 06 UNKNOWN t } 07 NONE VII LEAK DETECTION t } 01 VISUAL~ (X) 02 STOCK INVENTORY t ) 04'VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT C- D 06 GROUND WATER MONITORING WELLS t ) 07 PRESSURE TEST C } 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO`IV-1F YOUARENOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME)' STOPED STORED { ) 01 ( ) 02 ( ) 03 i- ( ) 01 ( ) 02 ( ) 03 } 01 ( ) 02 ( ) 03 f )' 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( 3 01 ( ) 02 ( ) 03 ( D 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( } 01 ( ) 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 (SIGNAT E) JPHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE l t" t., CONTACT PERSON PHONE W/AREA CODE DALE qOF LAST SPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID' # !�® ✓ j ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2