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STATE I0 NUMBER 00000057932003 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED f ) 02 ALKYD LINING t ) 03 EPDXY LINING t ) 04 PHENOLIC LINING f ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP t D 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( D 05 NONE t ) 06 TAR OR ASPHALT t ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING.: t ) 0:1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 7 07 NONE VII LEAK DETECTION (X) 01 VISUAL t ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( D 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 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 REgUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS#: (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( J 01 t ) 02 ( ) 03 t D 01 t ) 02 ( ) 03 ( ) 01 t ) 02 ( ) 03 t l 01 ( ) 02 ( ) 03 01 ( D 02 ( ) 03 ! J 01 t ) 02 ( ) 03 t ) 01 1 J 02 ( ) 03 t ) 01 ( _ J 02 ( ) 03 { ) 01 ( D 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( D 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 (SIGNATURE) PHO E W/Ap CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT EPSON PHONE W/AREA COD t 'c (Octn. q ;L_ 6 . y DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID S# ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2