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40 so STATE ID NUMBER 00000006115003 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED t ) 02 ALKYD LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. f l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN f 1 07 NONE VII LEAK DETECTION ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER= LINE LEAK DETECTORS VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU APE NOT PEPUIRED TO COMPLETE THIS SECTION CURRENTLY PP.EVICUSLY DELETE CAS# (IF KNCWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STO=ED STC;:-c0 ( ) 01 f 1 02 ( l 03 f 1 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( l 03 ( ) 01 ( l 02 ( 1 03 ( l 01 ( 1 02 ( ) 03 ( 1 01 ( l 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSONF L' :GN4 P • PHONE W/AP.EA CODE 7 17 FOR LOCA AGENCY USE ONLY ADMINISTRATING A.QE,�CY ` CITY CODE COUNTY CODE .SAIV Il U f iy CONTACT PERSON PHONE W/AREA CODE -) LAct. d X01 - 93/- s 39 e D4TE OF LAST INSPECTION IN COMPLIANCEPPOVAL DATE TRANSACTION DATE LOCAL PERMIT ID # O1 YES ( l 02 N;:ff� HSC04-070185 (10/18/85) PAGE 2