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STATE IO NUMBER 00000041041001 CONTAINER CONSTRUCTION E. 1 1 01 RUBBER LINED ( ) 02 ALKYD LINING l 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING 1 ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE 1 ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE l 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 ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION f 1 01 VISUAL ( ) 02 STOCK INVENTORY f 7 04 VAPOR SNIFF WELLS [ 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IP 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 f l 01 ( ) 02 ( ) 03 ( 101 ( 1 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 l 1 01 ( l 02 ( ) 03 f ) al ( 1 02 ( ) 03 f 1 Ol ( 1 02 ( ) 03 l ) 01 ( ) 02 ( ) 03 ( l Ol ( ) 02 ( ) 03 ( 1 Ol ( ) 02 f 1 03 ( 1 Ol ( ) 02 ( 1 03 R CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( I 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 FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID S ( ) 01 YES ( 1 02 NO HSC04-070165 (10/18/85) PAGE 2