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lime 'MF( STATE ID NUMBER 00000060082003 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f l 04 PHENOLIC LINING ( 1 05 GLASS LINING IX) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHL€NE WRAP [ ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: (\V1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) 04 04 PRESSURE (? 1 05 SUCTION ( 7 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER' VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS ZF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CASA (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOPED ( ) 01 ( ) 02 f 7 03 l ) 01 ( ) 02 ( ) 03 f 1 01 ( ) 02 f 7 03 f 1 O1 ( ) 02 ( ) 03 ( I O1 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 f 1 01 ( ) 02 f ) 03 f ] 01 ( 1 02 ( ) 03 1 l 01 ( ) 02 f ) 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. PER ON FILING (SIGNE) PMO E W/ EYl C001� as J 3 - 03 FOR OCA' AGENCY USE ONLY AOMZ NZSTRA TI G AGENCY )-f ` CITC F COUNTY CODE CONTA � PH DATE COD�JE _ lb DATE OF LAST INSPECTION I OMPLIANCE PERMIT APPROVAL DATE l/• TTRRAANSQI T PERSCACTION DATE LOCAL PERMIT ID R ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2