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i STATE IO NUMBER 00000065139001 CONTAINER CONSTRUCTION E. 1 ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING l ) 04 PHENOLIC LINING ( 1 05 GLASS LINING (X) 07 UNILINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. l ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION t ) 04 UNKNOWN ( ) 05 NONE (X) 06 TAR OR ASPHALT 1 ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING= 1 ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) OV 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING- ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE Vt ) 05 SUCTION ( l 06 UNWORN l 1 07 NONE VII LEAK DETECTION f ) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS l 1 05 SENSOR INSTRUMENT f ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 30 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 CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED 1 ) 01 f ) 02 1 ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) Ol f ) 02 1 ) 03 ( ) 01 ( ) 02 1 ) 03 ( ) 01 1 102 ( ) 03 f ) O1 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 f ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 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 TTHHEp PENALTY OF P RJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FIl NO ( ATUR!) \ PHP NZ CODE�. T FOR LOCAL AGENCY USE ONLY L/L� cam! J` �1/ ADMINISTRATING AGENCY ICITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 0 ( ) 01 YES 1 1 02 NO HSC04-070185 (05/05/86) PAGE 2