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I• STATE ID NUMBER 00000037573001 CONTAINER CONSTRUCTION 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 103 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE [ ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED IPE f l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f SUCTION t 1 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION f ) Ol VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT f 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( l 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 CAS# (IF KNOWN) CHEMICAL (DO.NOT USE COMMERCIAL NAME) STORED STORED f ) 01 ( ) 02 f ) 03 ( ) Ol ( ) 02 ( 1 03 f ] 01 t ) 02 f ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 t ) Ol ( 1 02 ( 1 03 ( 1 Ol f ) 02 ( ) 03 ( ) 01 ( ) 02 f 1 03 ( ) 01 f ) 02 ( 1 03 +( CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATEDON AN AGRICULTURALFARM? ( ) O1 YES (X) 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 E�CODE w6 t FOR LOCAL AGENCY USE ONLY p1 pV ADMINISTRATING AGENCYryy-(�`'(�' CI OE COUNTY CODE 50� 11 1 V CONTACT PERSO(/N� PHONE W/ARE CODE 1` q/ DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2 0 •