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CONTAINER CONSTRUCTION STATE 10 NUMBER 00000052937002 F RUBBER LINED ( ) 02 ALKYD LINING ( 7 03 EPDXY LINING [ ) 04 PHENOLIC LINING ( ) O5 GLASS LINING 07 UNLINED (X) OB UNKNOWN ( ) 09 OTHER:POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 7 05 NONE 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING EABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY PROPRIATE BOXES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 7 07 NONE ND PIPING: ( ) O1 OOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH03 GRAVITY PROPRIATE BOX(ES) (X) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) OS 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 CUPRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAM!) f l 01 ( ) 02 ( 1 03 I 1 Ol ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( 1 01 ( 7 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( ) 01 f l 02 ( ) 03 ( ) 01 f ) 02 ( ) 03 ( 1 03 ( 7 02 ( ) 03 ( ) _01 ( 102 ( ) 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 (SIGNATUREPHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 4 ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2