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CONTAINER CONSTRUCTION STATE ID NUMBER 00000019743001 E301 R LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING LINED (X1 08 UNKNOWN ( ) 09 OTHER: THLENE WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ) 05 NONE R OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 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 BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION _(X) 01 VISUAL ( ) 02 STOCK INVENTORY [ ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( 1 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 CA$# (IF KNOWN) STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) ( l 01 ( 1 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 I I ( 1 O1 ( ) 02 ( ) 03 ( 7 01 ( 1 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) O1 ( 1 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( T 01 ( ) 02 ( ) 03 ( 1 Ol ( ) 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 (SIGNATUFE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ZD # ( ) 01 YES ( 1 02 NO HSC04-070185 (10/18/85) PAGE 2 0 •