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STATE ID NUMBER 00000001441001 CONTAINER CONSTRUCTION E. C l 01 RUBBER LINED ( ) 02 ALKYD LINING C ) 03 EPDXY LINING E D 04 PHENOLIC LINING [ ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER= F. ( ) 01 PCLYETHLENE WRAP i ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN i ) 05 NONE ( ) 06 TAR OR ASPHALT t ) 09 OTHER= VI PIPING A. ABOVEGROUND PIPING= ( ) 01 DOUBLE-WALLED PIPE C 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE [ D 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION { ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( 1 10 OTHER= VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YCU CHECKED YES TO IV-F YOU ARE NOT RECUIRED TO COMPLETE THIS SECTION - CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) STOPED STORED ( ) OI C ) 02 ( ) 03 ( 101 ( ) 02 ( 1031111111111111 -- C ) 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 _ ( ) 01 ( ) 02 ( 1 03 -- ( ) 01 ( ) 02 ( 1 03 ( ) 01 ( 1 02 ( 1 03 l 1 01 ( 02 ( 1 03 ( ) O1 ( ) 02 ( ) 03 ( 1 01 ( ) 02 C ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS [ISCON�TAINER�LOCATEDN 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 FILING (SIGNATUP.E) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE C'O'NTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/65) PAGE 2 0