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CONTAINER CONSTRUCTION <br />STATE ID NUMBER 00000012661001 <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLY€THLENE WRAP f 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f 1 05 NONE <br />( ) 06 TAR OR ASPHALT { 7 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING• ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />4-tL-01 VISUAL (X) 02 STOCK INVENTORY F 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS [ 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br />VIII CHEMICAL COMPOSITION Of MATERIALS STORED IN UNDERGROUND CONTAINERS <br />i= YOU CHECKED YES TO IV -F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL :DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( J 01 <br />( ) 02 <br />( ) 03 <br />( 1 al <br />( ) 02 <br />( ) 03 <br />( ] 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( 1 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />f 1 01 <br />( ) 02 <br />( ) 03 <br />( 101 <br />( ) 02 <br />( 1 03 <br />f ) 01 <br />4 1 02 <br />( ) 03 <br />( 101 <br />( l 02 <br />( 1 03 <br />x CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />CS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br />THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />'EPSON FILING ISIGN.�URPNS � REA/S CODE <br />OR LOCAL AGENCY USE ONLY <br />ADMINISTRATING a�utQ/�4� G 3CITY CODE IGOUNTY CODE <br />CCNTACT PERSON PHONE W/AREA CODE <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE (LOCAL PERMIT ID # <br />( ) 01 YES ( ) 02 NO <br />1 HSC04-070185 (10/18/85) <br />PAGE 2 <br />