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STATE ID NUMBER 00000017756001 CONTAINER CONSTRUCTION -- __—] ( ) ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( l 05 GLASS LIN 01 RUBBER LINED LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: — _ ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE J ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: -- I PIPING ABOVEGROUND PIPING ( l O1 DOUBLE-WALLED PIPE ( ) 02 CO CRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE — UNDERGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE II LEAK DETECTION ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE ( l 10 OTHER: 'III CHEMICALs COMPOSITION U ARE OF RMATED To COMPLETE STORED SIENIDUNDERGROUND CONTAINERS IF YOU CHECKED TO :URRENTLY PREVIOUSLY DELETE CAStt (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOPED ( l 01 ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 O01 ( l02 ( 1031111111111111 ( l 01 O 02 O 03 I I �II I I O 01 O 02 O 03 I I I I I I I I I I f l 01 ( ) 02 ( ) 03 I I I ( ) 01 ( ) 02 ( ) 03 - ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 — * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS [IS:CO:NT�AINER LOCATED ON AN AGRICULTURAL FARM? ( l O1 YES (X) 0� NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PHONE W/AREA CODE PERSON FILING (SIGNATURE) FOR LOCAL AGENCY USE ONLY CITY CODE COUNTY CODE ADMINISTRATING AGENCY PHONE W/AREA CODE CONTACT PERSON DATE OF LAST INSPECTION IN COMPLIANCE PERMIT .4PPROV.4L DATE TRANSACTION DATE LOCAL PERMIT ID tt ( ) O1 YES ( ) 02 NO PAGE 2 HSC04-070185 (10/18/85)