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v ,r STATE ID NUMBER 00000004373004 CONTAINER CONSTRUCTION E. f ) 01 RUBBER LINED ( l 02 ALKYD LINING f 1 03 EPDXY LINING f ) 04 PHENOLIC LINING ( l 05 GLA55 LINING ( ) 07 UNLINED (X1 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( J 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X1 05 SUCTION ( l 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTI (p 01 VISUAL" ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT t 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU C"1ECK!D YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURPENTtY PREVIOUSLY DELETE EAS# (IF KNCWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STC,-EO STORED i ( 1 01 ( 1 02 ( 1 03 ( ) al ( ) 02 ( l 03 ( ] 01 ( l 02 ( 1 03 ( ) 01 ( ) 02 f ) 03 ( ) Ol ( ) 02 ( 1 03 ( 1 OI ( ) 02 ( l 03 ( l 01 ( ) 02 f ) 03 ( 1 01 ( ) 02 ( 1 03 i 1 01 ( 1 02 ( l 03 ( l 01 ( ) 02 ( l 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, PHO 'AREA COE ' s FOR LOCAL AGENCY SE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE fGfL-C ,CONT. T PERSON Rag PHNE W/A .EA CODE (�f MXA� / `!7 DATE OF LAST INSPECTION IN COMPLIANCE [PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PEPMIT ID V ( ) OS YES i ) C2 NO HSC04-070185 (10/18/85) PAGE 2 �.r