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f i STATE IO NUMBER 00000062064001 CONTAINER CONSTRUCTION E. C ) 01 RU88ER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( 7 05 GLASS LINING (X) 07 UNLINED ( ). 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( 7 04 UNKNOWN ( 7 05 NONE ( ) 06 TAR OR ASPHALT ( 7 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( J 05 SUCTION ( 106 UNKNOWN (. ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ! ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (.CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE f 1 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 7 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS Q�'1 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 CASA (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( 1 01 ( L 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 01 ( J 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 ( 7 01 ( ) 02 ( ) 03 ( > 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( 7 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 0.3 .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 COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FIL ( IGNA UR ) PHONE W/AREA CODE / 3L� -5216 FOR LOCAL AGENCY U E ONLY ADMLN TRATINj2_AGENCY �K //� / CITY CODE COUNTY CODE CONTACT PERSON-r-1PHONE W/AsA .ODEn life T � I k3ff- - s /(' DATE OF AST IjiSP ECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE .LOCAL PERMIT ID A PSP ( ) OS YES ( 1 02 NO MSC04-070185 (10/18/85) PAGE 2