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STATE ID NUMBER 00000016453001 CONTAINER CONSTRUCTION [ ) 01 RU55ER LINED ( ) 02 ALKYO L'NING l 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING i ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER- ( ) O1 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING t 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ! 05 NONE ( ) 06 TAR OR ASPHALT [ 1 09 OTHER: I PIPING ABOVEGROUND PIPING: ( 1 O1 DOUBLE-WALLED PIPE [ ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXiES) ( ] 04 PRESSURE [ 1 05 SUCTION ( ) 06 UNKNOWN ( ] 07 NONE UNDEP.GROU110 PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY (CHECK APFROPRIATE BOX(ES) 14 1 04 FRESSURE ( 1 05 SUCTION Wr+ 06 UNKNOWN [ 1 07 NONE II LEAK DETECTION O1 VISUAL [X1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS [ 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE 1 ) 10 OTHER: III CHEMICAL. COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS _F YCU CIAECKEO YES TO IV-F YOU APE NOT R:CUIREO TO COMPLETE THIS SECTION -GENTLY P?_VICUSLY DELETE CASC (IF 3;NOLJN) CMEMICAL (DO NOT USE COMMERCIAL NAME ) .'C?E3 STCPSC 01 ( ) 02 f ) 03 ] 01 [ ) 02 - i 1 03 ( 1 01 ( ) 02 ( ] 03 [ ) 01 ( 1 02 [ ) 03 r 01 ( 1 02 [ 1 03 ( ] 01 ( ) 02 ( 1 03 [ ) 01 ( 1 02 ( ) 03 [ 1 01 ( ) 02 ( ] 03 [ 1 01 ( ) 02 1 ) 03 ( ) 01 ( ) 02 1 ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS S CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES (X) 02 NO IS F` . S BEEN COMPLETED Ut]DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. FIL- f G,'7'r7 ) PHOME W;AREA CODE '7 �j l i OR LOCAL AGENCY USE ONLY MIST;A-ING AGENCY CITY CODE COUNTY CCDE � G CNTACT �SRSOM PH04E W/AREA CODE - ATE OF LAST INSPS^TION *M COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO f ) 01 YES l 1 02 NO .004-070185 (10/18/65) PAGE