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STATE ID NUMBER 00000012649002 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING f 1 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( 104 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT f ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE (XI 10 OTHER: LINE LEAK DETECTOR 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 STORED ( ) Ol ( ) 02 ( ) 03 ( ) O1 ( ] 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( 1 03 ( ) O1 f ) 02 ( 1 03 f l Ol ( ) 02 ( ) 03 f ) Ol f ) 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 ( ) of ( ) 02 ( ) 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. PS FILING I AT R p N W/AREA CODE r F R LOCAL AGENCY USE ONLY ADMZ NISTRATING AGENCY CITY CODE COUNTY CODE CONTA - PEP.SON PHONE :AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PlRMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT TO # ( ) O1 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2 _ .'(i'n