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STATE ID NUMBER 00000014289003 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD ( ;MING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( l 05 GLASS LINING i (X) 07 UNLINED ( ) 08 UNKN0;,'l ( ) 00 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING [ ) 03 CATHODIC PROTECTION ( l 04 UNKNOWN (X) 05 NONE ASPHALT 1 09 OTHF" I F ` 'IN" l 1 01 � ,.;LLL-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY CHECK APPROPPIAIE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE I F-W?r r rD f E f 1 n? C0NCRrTF-LTNFn TPFNJr" f 1 n i rp!!VTTY (CNT (X) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMLNt i ( ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER `dI: II CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU .ACE NOT REQUIRED TO COMPLETE THIS SECTION I CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) I STORED STOPED i ( i 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 I I I ( ) 01 ( ) 02 ( ) 03 I ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( l 02 ( l 03 ( l 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( l 02 ( l 03 ( ] 01 ( ) 02 ( l 03 ( 1 01 ( 1 02 ( l 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS [IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( ) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. ` PSON FILING (SIGNATURE ) PHONE W/AREA CODE to FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE i iCONTACT PERSON PHONE W/APE.A CODE iOA,TE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # I ( ) 01 YES ( ) 02 NO liSC04-070185 (10/18/85) PAGE 2