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STATE SO NUMBER 00000009065001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED f ) 08 UNKNOWN ( ) 09 OTHER: F. f 1 01 POLYETHLENE WRAP ( ] 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ('.) 04 UNKNOWN ( ) 05 NONE (xl 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLEQ_PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE (x) 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 (XI 05 SUCTION f ) 06 UNKNOWN l ) 07 NONE VII LEAK DETECTION ( 1 01 VISUAL ( ) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT f ) 06 GROUND WATER MONITORING WELLS 1 ) 07 PRESSURE TEST (X) 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 STORED ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 [ ) -01 ( ) 02 ( ) 03 f ) O1 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) al f ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES fX) 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 # f 1 01 YES ( ) 02 NO • NSC04-070185 (10/18/85) PAGE 2