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N." STATE !D NUMBER 00000019658005 CONTAINER CONSTRUCTION E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE (X) 06 TAR OR ASPHALT [ 1 09 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 (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) Ol DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX ES) (7C1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 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 CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED (X) 01 ( ) 02 1 ) 03 MOTOR OIL ( 1 01 f ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 f 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 7 01 ( 1 02 ( ) 03 ( ) 01 ( ) 02 ( 1 63 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l 01 YES (X) 02 NO THIS FORM HAS BEEN 6 aPLETED UNO ER TH N TY OF PERJURY AND, TO THE BEST OF MY KNONL£DGE, IS TRUE AND CORRECT. PERSON FIL NG ( A Rf) PHON! / EA CODE FOR LOCAL AGENCY USE ONLY ADMI NZSTRATI NO OE NCYCITY CODE COUNTY CODE CONT CT PERSON PN W/ NEA CODE DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( 1 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2 `00