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STATE ID NUMBER 00000008259001 CONTAINER CONSTRUCTION E. [ 101 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING f ] 04 PHENOLIC LINING [ 1 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. f ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ] 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT f ] 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 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 LW03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN f 1 07 NONE VII LEAK DETECTION W,4, 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ;& 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-? YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 [ 1 01 ( ) 02 ( ) 03 ( 7 01 ( ) 02 ( ) 03 ( ) 01 l ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 1 ) al ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 - ( ) Ol ( ) 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 TH NALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PEPSON FIL (SIG1jA TURF ) PHONE W/AREV �_ FOR LOCAL AGE CY USE NLY ADMI NISTRATI NO AGENCY CITY CODE q COUNTY COOL IT / / CONTACT PERSON PHONE W/AREACODE vol- DATE OF LAST INSPECTION INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PCRMIT ID # ( ) O1 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2