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%ww� J STATE ID NUMBER 00000003367003 CONTAINER CONSTRUCTION E. l 7 01 RUBBER LINED ( l 02 ALKYD LINING ( ) 03 EPDXY LINING f ] 04 PHENOLIC LINING ( ) OS GLASS LINING 1X1 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. (X) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( ] 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 1 05 NONE ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION [X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: f ) Ol DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION `( ) 01 VISUAL ( 7 02 STOCK INVENTORY f ) 04 VAPOR SNIFF HELLS ( ) OS SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 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 CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED (X) 01 ( ) 02 ( 1 03 WASTE WATER (PROCESS OR INDUSTRIAL) (X) 01 f ) 02 ( ) 03 PESTICIDES ( 1 01 ( ) 02 1 1 03 f 1 01 ( ) 02 ( ) 03 ( ] Ol ( l 02 ( 1 03 ( ) Ol ( ) 02 ( ) 03 ( I 01 1 ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 Ol ( ) 02 ( ) 03 ( l Ol ( ) 02 ( ) 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 (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY COO E COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( l 01 YES ( 1 02 NO HSC04-070185 (10/18/85) PAGE 2 Li