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STATE ID NUMBER 00000003446001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( l 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( l 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (\J 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUN ER MONITORING WELLS ( l 07 PRESSURE TEST (X) 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 CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( l 02 ( ) 03 f ) 01 ( ) 02 t ) 03 ( 1 01 t ) 02 ( ) 03 ( l 01 t ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 ( 1 02 ( l 03 ( ) 01 ( ) 02 ( l 03 ( ) 01 ( l 02 ( ) 03 ( ) 01 ( l 02 ( l 03 ?( CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS SIS CONTAINER LOCATED ON AN AGRICULTURAL FARM?_( l 01 YES (X) 02 NO THIS FORM HAS BEEN CCMPLET, U1(DEP. THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. gEpSON IN^ GN R PHONE W/-z 6 5 ODE 6 FOR LOCAL AGENCY USE ONLY Q� J AOMINISTPATIN3 AGENCY ( S 7 CITY CODE COUNTY CODE fi,q J V i C - CONTACT PER4,oL -d PV/ -( -/ PHONE W/AREA CODE 04TE OFLAST INSPECTION IN COMPLIANCE PEP,MIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # i _� ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2