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STATE ID NUMBER 00000021724002 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP f ] 02 VINYL WRAPPING ( 103 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT f 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: ( ) Ol DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN f 1 07 NONE VII LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY l ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( l 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STOPED I 1 01 ( ) 02 ( 1 03 ( 1 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f ) O1 f ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 f 1 01 ( ) 02 ( ) 03 f ) O1 ( ) 02 ( ) 03 l 1 Ol ( ) 02 ( 1 03 ( ) al f ) 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. PERSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) O1 YES f 1 02 NO HSC04-070185 (10/18/85) PAGE 2