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�.. r STATE ID NUMBER 00000019658008 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING (XI 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING f 3 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE (X) 06 TAR OR ASPHALT f 1 09 OTHER= VI PIPING A. ABOVEGROUND PIPING( ( ) 01 DOUBLE-WALLED PIPE [ ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f ) 05 SUCTION (X) 06 UNKNOWN ( 1 07 NONE B. UNDERGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY . (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE WH 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION f 1 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF )(ELLS f ) 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 CAS# (IF KNOWNI CHEMICAL (00 NOT USE COMMERCIAL NAME) STOPED STOPED (X) 01 ( ) 02 ( ) 03 MOTOR OIL ( ) 01 ( ) 02 ( ) 03 ( 1 O1 ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 ( ) O1 ( 1 02 ( ) 03 f 7 01 ( ) 02 ( 1 03 ( 1 01 ( ) 02 ( ) 03 ( ). O1 [ ) 02 ( 1 03 ( 1 al f 1 02 ( ) 03 R CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HAS N COMPLETED UND E LTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PER N FI 0 uSIGNATURE) PHO /AREA CODE FOR LOCAL AGENCY USE ONLY ADMZ NI ST RATI NtL AOE NCYCITY COD! COUNTY COD! CONTACT PERSON P E W/ REA CODE GATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( > 01 YES ( I 02 NO HSC04-070185 (10/18/85) PAGE 2 Some two