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STATE 10 NUMBER 00000033205001 CONTAINER CONSTRUCTION . E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( } 03 EPDXY LINING { D 04 PHENOLIC LINING f J 05 GLASS LINING ( ) 07 UNLINED (X) '08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 2 02 VINYL WRAPPING ( } 03 CATHODIC PROTECTION (X) 04 UNKNOWN t l 05 NONE ( ) 06 TAR OR ASPHALT ( D 09 OTHER: .. VI PIPING' A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 105 SUCTION ( ) 06 UNKNOWN t D 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( d 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION t ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST t ) 09 NONE ( d 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV—F -YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED f D 01 ( ) 02 t 103 ( D 01 ( ) 02 ( ) 03 ( ) 01 ( ') 02 t ) 03 ( J 01 ( ) 02 t D 03 ( D 01 f ) 02 ( l 03 ( ) 01 f )'02 ( ) 03 ( ) 01 ( l 02 ( ) '03 ( `l 01 t D 02 t l 03 ( :l 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 *CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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. PERSON FILING (SIGNATURE) PHONE W/AR A CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITC E COUNTY CODE a Y\ . 1 o r( CONTACT,PERSONG � � � PHONE W/AREA CODE DATE OF LAS NSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 9