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STATE ID NUMBER 00000058626005 CONTAINER CONSTRUCTION E. f 1 01 RUBBER LINED ( 1 02 ALKYD LINING f ) 03 EPDXY LININ f ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING [ l 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE L 1 0.2 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE Q04 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE S. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X). OS SUCTION f 1 06 UNKNOWN ( ] 07 NONE VII LEAK DETECTION ( 1 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECK!D YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) C141MICAL (DO NOT USE COMMERCIAL NAME) STORED STORED l 1 01 ( ) 02 ( ) 03 ( 101 ( ) OE ( ) 03 ( 1 01 ( ) 02 ( ) 03 f l 01 ( ) 02 ( ) 03 ( l O1 ( ) 02 ( 1 03 ( ) al ( 1 02 ( ) 03 ( 1 Ol f l 02 ( 1 03 ( l 01 ( ) 02 l 1 03 ( 1 Ol f ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES ( 1 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON ND ( AT ) PHONE W/AREA CODE 0 FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY C00! CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO Y. ( ) 01 YES t ) 02 NO MSC04-070185 (10/18/65) PAGE 2