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STATE ID NUMBER 00000012406003 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING [ ) 03 EPDXY LINING f 1 04 PHENOLIC LINING f l 05 GLASS LINING (XI 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 102 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X1 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f l 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 ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE f 105 SUCTION ( 1 06 UNKNOWN ( 107 NONE VII LEAK DETECTION 4* 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT f 1 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-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION / CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) ( STORED STOPED ( 7 01 ( ) 02 ( ) 03 1 1 01 ( ) 02 ( )- 03 ( ) O1 ( ) 02 ( ) 03 ( ) el ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 81 ( ) 02 ( ) 03 ( 101 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 f ) 02 ( 1 03 1 ) 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 OE PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PMO NE W/AREA CODE a''I S 7�Z ZOS / FOR LOCAL AGENCY USE ONLY ` ADM2 NI ST ATINO AGENCY /� OITY CODE COUNTY CODE /V/ SGT CONTACT P SON PX E W/AREA CODE DATE OF LAST INSPECTION IN COMPLIA NC! PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( 1 O1 YES ( 1 OE NO HSC04-070185 (10/18/85) PAGE 2