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CONTAINER CONSTRUCTION STATE ID NUMBER 00000011239001 E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING f ) 04 PHENOLIC LINING f ) OS GLASS LINING ( 1 07 UNLINED (X) 08 UNKNOWN ( l 09 OTHER: F• ( ) O1 POLYETH LENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 7 05 NONE ( l 06 TAR OR AgpHAIT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 0 1 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ] 03 GRAVITY fCH FCK gppgOpRIATE 80Xf ESI ( ] 04 PRESSURE ( 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE B. UNDERGROUND PIPING: ( 1 O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 ( 1 05 SENSOR INSTRUMENT PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER: IF YOU CHECKED VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CASO (IF KNOWN) i STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) ( 101 ( ) 02 ( ) 03 ( ) 01 f ) 02 ( ) 03 f 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 f ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( 1 O1 ( ) 02 ( ) 03 f ) 01 f l 02 ( 1 03 ( l 01 f ) 02 ( ) 03 ( ) 01 ( 1 02 ( 1 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 (SIG TORE) PHONE W/AREA CODE c.L� E".�•... FOR LOCAL AGENCY SE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/ARCA CODE DATE OF LAST INSPE ( ) O1 YES f ) PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ZD 02 )t HSC04-070185 (10/18/85) PAGE 2