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STATE ID NUMBER 00000017798007 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( 1 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. t ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f 103 CATHODIC PROTECTION (X1 04 UNKNOWN l ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING• f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) 1 4 PRESSURE ( 1 05 SUCTION (*t-06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS t ) 07 PRESSURE TEST (X) 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 CAS4 (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STOPED STORED [ ) 01 ( ) 02 ( ) 03 ( ) Ol 1 ) 02 ( 1 03 ( 1 Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 l ) O1 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f ) al ( ) 02 ( ) 03 f 1 Ol ( ) 02 ( 1 03 ( ) al ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 FIL S ON T RC) ♦ PHONE W/AREA CODE 6� 0 CYT.Z5� FOR LOCAL AGENCY USE ONLY ACMS NS iRATINTO AGENCY c'TY CODE COUNTY COD! v CONTACT PERSON PH NE W/AREA CODE DAT! OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL GATE TRANSACTION QAT! LOCAL PERMIT ZO 4 l 1 01 YES f ) 02 NO HSC04-070185 (10/18/85) PAGE 2