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r CONTAINER CONSTRUCTION STATE ID NUMBER 00000062853004 E. ( ) 81 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING (X') 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER. F. ( ) 01 POLYETHLENE WRAP C 1 02 VINYL WRAPPING t l 03 CATHODIC PROTECTION - ( ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( l 09 OTHER: PIPING INt A. AWVEGROUND PIPING: ( l 01 DOUBLE -WALLED PIPE ( l 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN L;�J.07 NONE B. UNDERGROUND PIPING: ( J 01 DOUBLE -WALLED PIPE ( ) 0.2 CONCRETE -LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( ) 05 SUCTION ("') 06 UNKNOWN ( X.07 NONE VII LEAK DETECTION 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT C ) 06 GROUND WATER M041TORING WELLS ( 07 .PRESSURE TEST ( ) 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 STORED PREVIOUSLY STORED DELETE GAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 E ) 03 ( ) 02 ( ) 0.3 ( ), gl. ( ) 02 ( ) 03 ( 7 Oi ( ) 02 ( ) 03 l 01 t ) 02 ( ) 03 01 ( 1 02 ( ) 03 >? ) O1 ( ). 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 l 01 ( ) 02 ( ) 03 *CHECK STATE BOARD CHEMICAL CODELISTINGFOR POSSIBLE SYNONYMS IIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO CHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND; TO THE BEST OF MY KNOWLEDGE, IS TRUE ANU CORRECT. PERSON F LI G (SIGNATUR PHONE W/AREA CODE ,V'7 c2-0 9 '�/'7 J 7 G (I R LOCAL AGENCY US -E ONLY ADMLNISTRATING AGENCY CITY CODE COUNTY CODE CONTAC PERSON C PHONE W/AREA CODE r DATE OF LAST INSPECTION . N COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2