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STATE IO NUMBER 00000054749003 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ! 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. f ) 01 POLYETHLENE WRAP ( ! 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT f 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING' ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( l 06 UNKNOWN ( l 07 NONE VII LEAK DETECTION [ ) O1 VISUAL ( ) 02 STOCK INVENTORY f l 04 VAPOR SNIFF WELLS [ ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS f 107 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 STORED (X) 01 ( ) 02 ( ) 03 15171515161 PROPYLENE GLYCOL ( 1 01 f ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( l 03 f ) O1 ( ) 02 ( ) 03 l ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 l 1 01 f ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? i ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLE D UND THE PENALTY PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIONATUR I PHONE W/AREA CODE FOR LOCAL AGENCY USE ON ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATC TRANSACTION DATE LOCAL PERMIT 10 # ( ) O1 YES [ ) 02 NO HSC04-070185 (10/18/85) PAGE 2