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L �.../ STATE ID NUMBER 00000006848002 CONTAINER CONSTRUCTION E. f 1 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING l 1 04 PHENOLIC LINING ( 1 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( 109 OTHER: VI PIPING A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) _,04 PRESSURE (X) OS SUCTION ( ] 06 UNKNOWN f 1 07 NONE VII LEAK DETECTION ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 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 REQUIRED TO COMPLETE THIS SECTION CUPPENTLY PREVIOUSLY DELETE CASA (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED ( ) al ( ) 02 ( ) 03 ( ) 01 ( ) 02 f ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) Ol f ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 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 BEEN MPLETE ER THE P ALTY OF PERJURY AND. TO TME BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FSLIN I TU ) PHONE W/AREA CODE NoelFOR LOCAL AGENCY USE ONLY ADMIN STRATINO AGENCY CITY COD! COVNTY CODE CONTA T PERSON PMO E W/AREA CODE-m 04TE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID A ( ) O1 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2