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• STATE ID NUMBER 000000002264001 rfl4 CONSTRUCTION LINED ( 1 02 ALKYDLINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING05 GLASS LINING NED I 1 08 UNKNOWN ( 1 09 OTHER F. 1 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (XI 05 NONE f ) 06 TAR OR ASPHALT ( 1 09 OTHER ✓I PIPING �A. ABOVEGROUND PIPING l 1 O1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY (CHECK APPROPRIATE BOX(ESI ( 1 )4 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE L B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE l 1 OS SUCTION ( ) 06 UNKNOWN ( ) 07 NONE 4✓II LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS l 105 SENSOR INSTRUMENT l 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST 1 1 09 NONE ( 1 10 OTHER: LIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED i ES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) STORED STORED (X) 01 ( 1 02 ( ) 03 I I I I I I I I I I LUBRICATING OIL 4 (X) 01 ( ) 02 ( ) 03 I I I I I I I I I I I SEDIMENT AND SLUDGE ( 1 01 [ ) 02 ( ) 03 ( 1 01 ( 1 02 ( ) 03 I I ( 1 01 ( ) 02 f 1 03 f l 01 l ) 02 ( 1 03 4 l 1 O1 ( ) 02 ( ) 03 I ( 1 01 ( ) 02 ( 1 03 l 1 01 ( ) 02 ( ) 03 ( 1 01 l 1 02 ( ) 03 LP CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS LIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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. PERSONF NO (SIORAT PE . Q/ i PXON'o^AREA CODE FOR LOCAL AGENCY/LU/SE ONLY,� J ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DOTE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID X ( ) 01 YES ( ) 02 NO k: H�,0�=070165 f10/18/851 PAGE 2