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STATE ID NUMBER 00000011196003 CONTAINER CONSTRUCTION E. { 1 01 RUBBER LINED ! ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING {X) 07 UNLINED ( i 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP t 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING- ( 1 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH C ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE I ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: { ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) i ) 04 PRESSURE (X) 05 SUCTION f 1 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( ) 01 VISUAL {X1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS I ) 05 SENSOR INSTRUMENT i ) 06 GROUND WATER MONITORING WELLS 1 ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF 1'CU CHEC)CEC YES TO :V-F YCU ARE NCT PECU'-RED TO CCt'.PLETE THIS SECTION CUFPENTLY PPEVIOJSLY DELETE CASO (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) STCPED STC=`_C { r 01 ( ) 02 1 1 03 O Ol O 02 1 ) 03 ( i 01 ( 1 02 f 1 03 ( ) 01 ( ) 02 ( 1 03 ( 1 01 l ) 02 ( I 03 ( 1 01 { ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 ( ) 01 ( i 02 ( 1 03 ( 1 01 ( ) 02 ( 1 03 ( r 01 ( 1 02 { 1 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS LIS CONTAIIIER LOCATED ON AN AGRICULTURAL FARM? ( I 01 YES {X1 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. c�-SON F:L:':G (S:GNATUPE PHONE W/AREA CCOE D FOR LOCAL AGENCY USE ONLY t�"IN.STP4T:h°G 6:�`:Cl CITY CODE CCUNTS CCCE — -- _.-c NE W/ACEA CODE P EFS C N --- ---------------- DATE OF LAST :NSPECT:CN ?N COMPLIANCE FEPMIT APPPOVAL DATE TRANSACTION DATE '– – LCCAL PERMIT I0 E )ES 7 02 NO HSC04-070185 (10/18/85) PAGE 2