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r� STATE ID NUMBER 00000039023002 CONTAINER CONSTRUCTION E. l ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING ( ) 07 UNLINED (X) OB UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING l 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ] 05 NONE ( ) 06 TAR OR ASPHALT ( l 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 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 ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN f 7 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT [ ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST OW 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 ( 1 01 ( ) 02 ( ) 03 ( 1 01 f ) 02 ( 1 03 l ) Ol ( 1 02 ( 1 03 l 1 01 ( l 02 f l 03 ( ) 01 1 l 02 ( ) 03 ( 1 O1 ( 1 02 ( ) 03 ( 1 01 ( 1 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 7 01 ( ] 02 ( ) 03 - ( ) al ( ) 02 ( ) 03 ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l 01 YES (X) 02 HO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING ( ONA E) PHONE W/AREA CODE 09, 6 FOR LOCAL AGENCY USE ONLY ADMINIST TING AOC NCY CITY CO E COUNTY CODE CONTACT PERSON P HE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( 1 OC ND HSC04-070185 (10/18/65) PAGE 2