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.1 STATE ID NUMBER 00000007036002 CONTAINER CONSTRUCTION E. ( l 01 RUBBER LINED l 1 02 ALKYD LINING (XI 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( l 05 GLASS LINING f ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) G4 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT ( ] 09 OTHER: rVI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE [ 102 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) OS SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f 1 05 SUCTION ( 7 06 UNKNOWN f ) 07 NONE LEAK DETECTION ( 1 01 VISUAL ( 7 02 STOCK INVENTORY 1 ) 04 VAPOR SNIFF WELLS l 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE f ) 10 OTHER= VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REgUIREO TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( ) 02 ( ) 03 ( 1 Ol ( ) 02 ( 1 03 ( ) Ol ( 1 02 ( 1 03 ( l Ol ( ) 02 f ) 03 1 l Ol ( ) 02 ( 1 03 f 1 al ( ) 02 ( ) 03 ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 f 1 03 ( ) Ol ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS JIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AMD, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. LPERSON FILING (SIGNATURE) PHONE W/AREA CODE rOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( 1 O1 YES ( ) 02 NO 04-070185 110/18/85) PAGE 2 \�