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STATE IO NUMBER 00000054749006 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 7 03 EPDXY LINING ( 1 04 PHENOLIC LINING (X) 05 GLASS LINING [ ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. 1 ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE L ) 06 TAR OR ASPHALT f ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 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 f ) 05 SUCTION ( ) 06 UNKNOWN f l 07 NONE VII LEAK DETECTION ( 1 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT t ) 06 GROUND WATER MONITORING WELLS f 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) STORED STORED (X) 01 ( ) 02 ( ) 03 121912111818121 • CHLORPYRIFOS (CHROMATE) ( ) 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( ) Ol ( ) 02 1 ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) al ( ) 02 ( ) 03 ( ) 01 ( ) 02 f 1 03 ( 1 01 ( ) 02 ( 1 03 f ) 01 ( ) 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 COMPLE D UNDN THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PCRSON FILING (SIONATUR PHONE W/APEA CODE FOR LOCAL AGENCY USE 0 LY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTIONIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES f ) 02 NO HSC04-070185 (10/18/85) PAGE 2 `/ V