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`. STATE IO NUMBER 00000060392004 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING l ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. f ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER'- VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (. ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( > 07 NONE VII LEAK DETECTION ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( l 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 PEgUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME1 STORED STORED ( 1 Ol ( l 02 ( ) 03 ( 1 O1 f ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( l 01 f ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 ( 1 01 ( ) 02 ( ) 03 l ) 01 ( 1 02 ( ) 03 ( ) 01 l 1 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 YES ( ) 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 CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANC! PERMIT APPROVAL DATE TRANSACTION DAT! LOCAL PERMIT ID # ( ) O1 YES f 1 02 NO HSC04-070185 (10/18/85) PAGE 2