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�./ STATE IO NUMBER 00000041688003 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING [ ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION f 1 04 UNKNOWN ( 1 05 NONE (X) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH [ ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION [Xl Ol VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( l 06 GROUNO WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE ( ] 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO T.V-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED (X) 01 ( ) 02 ( ) 03 OIL AND WATER MIX f ) 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 l ) 01 ( ) 02 ( 1 03 ( 1 al ( 1 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 f ) O1 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 l ) 01 ( ) 02 ( ) 03 ( ) O1 ( ) 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 (SIGNATURE) PHONE W/AREA CODE o FOR LOCAL AGENCY USE ONL ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF •LAST IyNSSPPPEECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # Ol YES ( / 02 NO HSC04-070185 (10/18/85) PAGE 2