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r STATE ID 'NUMBER 00000054576005 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f } 03 EPDXY LINING ( 9 04 PHENOLIC LINING ( } 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN t ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION t ) 04 UNKNOWN (X) OS NONE t } 06 TAR OR ASPHALT E b 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE C ) 02 CONCRETE--LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t ) 05 SUCTION E ) 06 UNKNOWN E } 07 NONE B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( D 06 UNKNOWN [ ) 07 NONE VII LEAK DETECTION! (X) 01 VISUAL ( ) 02 STOCK INVENTORY t l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT f ) 06 GROUND 'WATER MONTTORINfG WELLS t ) 07 PRESSURE TEST ( ) 09 NONE t D 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REOUIPED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CTAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) I STORED STORED { )! 01 ( ) 02 ( ) 03 t ) 01 O 02 O 03 ( ) Ol t ) 02 ( ) 03 t l 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 -( }; 01 ( ) 02 ( ) 03 I i t 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 C ) 01 ( ) 02 ( ) 03 { ) 01 ( ) 02 ( ) 03 HECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS 'FIS 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 F LI G (SIGNA U E) PHONE W/AREA CODE ® IS 3 FOR+ CAL VGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE i DATE OF LAST INSPECTION IN COMPLIANCEPERMIT :APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # ( ) 01 YES ( ) 02 NO DSC04-070185 (10/18/85) PAGE 2