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r STATE ID NUMBER 00000058945001 CONTAINER CONSTRUCTION E. l ) 01 RUBBER LINED [ 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 103 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 1 05 NONE (X) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 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 (X) .05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( l 02 ( 1 03 ( 1 01 ( 7 02 f ) 03 ( ) 01 ( ) 02 ( 1 03 f ) 01 ( ) 02 ( ) 03 f 1 01 ( l 02 ( ) 03 ( 101 ( ) 02 ( ) 03 - ( 1 01 f l 02 f 1 03 ( ) 01 ( ) 02 ( ] 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( 1 03 �( CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 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. PE P.SON FILING ( TURE7 j PHONE W/A^R t CODE L// 3% FOR LOCAL AGENCY USE ONLY 7 !/� ADMINISTRATING AGENCY 1)!S7 CITY CODE COUNTY CODE S/1/V �R�Lt lA/ L�/t -�tC / A �7(l� CONTACT PERSON PHONE W/AREA CODE /m-r �/ *' p Y DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # I _ �s i F7 01 YES ) 02 NO HSC04-070185 (10/18/85) PAGE 2