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STATE ID NUMBER 00000047737001 CONTAINER CONSTRUCTION EF ( O1 RUBBER LINED ( 1 02 ALKYD LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING 107 UNLINED (X) 08 UNKNOWN t ) 09 OTHER: O1 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION04 UNKNOWN ( ) 05 NONE ) 06 TAR OR ASPHALT ( ] 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( 1 02 CDNCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE S. UNDERGROUND PIPING: [ ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION (Xl O1 VISUAL ( l 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( 1 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 l 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 ( ) Ol ( 1 02 ( l 03 ( I O1 ( ) 02 ( ) 03 ( ) 01 l 1 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 l ) 01 ( ) 02 ( ) 03 [ ) 01 ( ) 02 ( ) 03 ( 1 Ol ( 1 02 ( ) 03 ( ) 01 ( ) 02 ( 1 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 (SIGNATURE) PHONE W/AREA CODE C, FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # 1 ) O1 YES f ) 02 NO HSC04-070185 (10/18/851 PAGE 2