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STATE ID NUMBER 00000001224001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING f ) 05 GLASS LINING ( 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ] 02 VINYL WRAPPING ( ] 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT f 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE A 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (k 05 SUCTION ( l 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT 1 ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF 1'OU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PP.EVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STOPED STOPED ( ) 01 f 102 ( ) 03 ( ) O1 f l 02 ( 1 03 ( l Ol f ) 02 ( 1 03 ( ) 01 ( ) 02 ( 1 03 f ) of 1 1 02 1 1 03 ( 1 Ol ( ) 02 ( ) 03 l 1 Ol ( ) 02 ( ) 03 ( 1 O1 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) 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 COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON SIONAT PHONE W/AREA CODE fo FOR LOCAL AGENCY U E ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA COD! DATE OF LAST INSPECTION IN COMPLIANC! PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2//`