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STATE ID NUMBER 00000009414004 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING t ) 04 PHENOLIC LINING t ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP t D 02 VINYL WRAPPING E l 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ('X) 05 NONE ( ) 06 TAR OR ASPHALT t ) 09 OTHER= VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE { l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN (' ) 07 NONE B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED.TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t ) 05 SUCTION ( D 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION' ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS t l 05 SENSOR INSTRUMENT 06 GROUND WATER MONITORING WELLS t ) 07;PRESSURE TEST (X) 09 NONE ( ) 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 (00 NOT USE COMMERCIAL NAME) STORED STOPED 01 t ). 02 ( ) 03 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 (' ) 01 t ) 02 O 03 t ) 01 ( ) 02 ( ) 03 ( .) 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03- I t l 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 - t ? 01 ( ) 02 t ) 03 ' CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS �I' CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO TH S FORM HAS BEEN'COMPLETEO UNDER THE PENALTY OF PERJURY ANO, TO THE BEST OF MY KNOWLEDGE: IS TRUE AND CORRECT. P R50N FILING (SIGNATURE) PH W/AREA CODE g� } m� FOR LOCAL AGENCY USE ONLY 11 ADMINISTRATING AGENCYCITY CODE COUNTY CODE CONTACT PERSON ]PHONE W/AREA CODE DATE OF LAST INSPECTION YN COMPLIANCE PERMIT APPROVAL DATE F ANSACTION DATE LOCAL PERMIT ID # ( ) Ol YES ( ) 02 NO HSC:04-070185 (10/18/85) PAGE 2