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UA_ . STATE ID NUMBER 00000011196001 CONTAINER CONSTRUCTION E. 1 ) 01 RUBBER LINED ( 1 02 ALKYD LINING l 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING t ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. f 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f ] 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( 109 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE lX) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST ( ) 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 CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STOPED ( L O1 ( ) 02 ( 103 ( ) 01 ( ) 02 1 ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ! ) 01 ( ) 02 ( 1 03 l ) 01 ( ) 02 ( 103 1 ) 01 ( ) 02 ( 103 f ) Ol ( ) 02 ( 103 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 w CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES fX) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. GEGSON FILIRO fSiGNATUPEI PHONE W%AREA CODE FOR LOCAL AGENCY USE ONLY AOMINiSTRATING AGE N'CY� CITY CODE CCUNTI CODE 39 CONTACT PEPSON PHO F W/AR A CODE `�ILi DATE OF LAST INSPECTION IN COMPLIANCE PER TION DATE LOCAL PERMIT I0 K ( ) 01 YES 1 1 02 NO HSC04-070185 (10/18/851 PAGE 2