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� 1 STATE ID NUMBER 00000003443004 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPIG Nl ) 1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) 04 PRESSURE N*r 05 SUCTION ( l 06 UNKNOWN f ) 07 NONE VII LEAK DETECTION f ) 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS Oki 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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 f 1 01 ( ) 02 ( l 03 l 1 O1 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 l ) 01 ( ) 02 ( ) 03 ( 1 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. PERSON FILING (SIGNpTyREI/ / P"OKe__W/APEAOEA COD! / FOR LOCAL AGENCY USE ONLY AOMINI STRATING AGENCY CITY CODE COUNTY COD! t5Zc�- CONTACT PER SONU PMQNE W AREA CODE � DATE OF LAST INSPlCTION IN COMPLIANCEPlRMIT APPROVAL DATE TRANSACTION DAT! LOCAL RERMIT ID # ( ) 01 YES ( 1 02 NO HSC04-070185 (10/18/85) PAGE 2 \.00