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STATE 10 NUMBER 00000030765 r , CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) :02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( l 05 GLASS LINING (X) 07 UNLINED t ) 08 UNKNOWN ( ) 09 OTHER= F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION t ) 04 UNKNOWN (X) 05 NONE t )' 06 TAR OR ASPHALT -t ) 09OTHER'- VI PIPING A. ABOVEGPOUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH t ) 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 (X) 03 GRAVITY (CHECK APPROPRIATE B0X(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN t ). 07 NONE VII LEAK DETECTION tX) 01 VISUAL ( ) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS t 107 PRESSURE TEST ( ) .09 NONE ( ) 10 OTHER: JIII CHEMICALCOMPOSITIONOF 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) STOPED STORED (X) 01 ( ) 02 ( ) 03 1 1 16111 -F4d ft- 01 ( ) 02 ( ) 03 C D 01 ( ) 02 ( l 03 ( 101 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( l` Ol ( ) 02 t ) 03 t 3 Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 t 3 01 ( ) 02 ( ) 03 t D` 01 ( ) 02 t 1- 03 # CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS 1S CONTAINER LOCATED ON AN AGRICULTURAL FARM? t' D 01 YES (X) 02 NO "THIS FORM EN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERS FI 43 MiTE) PHONE W/AREA CODE FOR LOCAL AGENCY -'E ONLY ADMINISTP.ATIN3 AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA COBE ; DATE OF LAST INSPECTION IN COMPLIANCE PERMIT AP.PROVAL'DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) AI' YES ( ) 02 NO (SC0t=070285 fi0ll8/85I PAGE 2