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STATE ID NUMBER 00000046264001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYO LINING f 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING f l 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( l 04 UNKNOWN ( 1 05 NONE (X) 06 TAR OR ASPHALT f ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: [ ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 30 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YCU APE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVICJSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOP''-D STORED ( ) 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( 1 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 ( ) 01 ( 7 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 ( ) 01 ( ) 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 COMPLE EO U DER THE PEN TY O PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILIN3 (SIGNATU - ) PHONE WIR A 004� -4G O FOR LOCAL AGENCY USCOLY [[f(�� AJMINCSTPAT"NG AGENCY CITY �0 COUNTY CODE Sa>1 ci �r CONT CT PERSON G PHON W/AREA CODE �I - �� DATE OF LA i PECTION IN COMPLIANCE PERMIT APPROVAL DATE TRR/AANSSAACITIONf.Dl(ATE/(O LOCAL PERMIT ID it ( ) O1 YES ( ) 02 NO HSC04-070185 (10/18/851 PAGE 2 ! i