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STATE ID NUMBER 00000018272001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( l 05 GLASS LINING (X) 07 UNLINED t ) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE (X) 06 TAR OR ASPHALT ( l 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRE) H ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) 1, 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN (N 07 NONE VII LEAK DETECTION ( l 01 VISUAL ( ) 02 STOCK INVENTORY (X) 04 VAPOR SNIFF WELLS ( ) 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 APE NOT REQUIRED TO COMPLETE THIS SECTION CUP.PENTLY PP.EVZOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) STORED STOPED ( ) 01 ( l 02 ( l 03 ( l 01 ( 1 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( l 01 ( l 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 f ) 02 ( ) 03 ( ) 01 ( l 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 * 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 FILING (SIGN.ATURE) ZPONE /AREA DE �v -2-1 L FOR LOCAL AGENCY US ONLY ADMINISTRATING AGENCY CITY gD, COUNTY CODE oma„ —'llll CONTA T PEPSON PHONE /AREA CC E c geg 13 DATE OF LAST Z PECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID a ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2