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STATE ID NUMBER 00000065270001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING t ) 05 GLASS LINING ( ) 07 UNLINED ( ) 08 UNKNOWN (X) 09 OTHER: RESIN-EPDXY F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( 109 OTHER= VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY !rr (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING= t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN [ ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( )_04 VAPOR SNIFF WELLS (X) 05 SENSOR INSTRUMENT (X) 06 GROUND WATER MONITORING WELLS (X) 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( ) 02 ( ) 03 E ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 t ) Ol ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 t ) Ol ( ) 02 ( ) 03 t ) Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 t ) 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 BEENCOMPLETEDUNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON Fi G (S� TURE) PHONEJW/AREA CODE FOR LOCAL AGENCY USE ONLY ADMI STRA�G AGENCY CITY CODE COUNTY CODE CONTACERN ONE W/AREA CODE DATE FAST I P CTION IN COMPLIANCE PMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # �3� k� ER( ) 01 YES t ) 02 NO HSC04-070185 (05/05/86) PAGE 2