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STATE ID NUMBER 00000009483001 CONTAINER CONSTRUCTION 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 7 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 7 04 UNKNOWN ( ) 05 NONE (X) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 7 01 DOUBLE-WALLEQe,PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE O(7 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE S. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 7 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( 1 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( 1 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 (00 NOT USE COMMERCIAL NAME) STORED STOPED ( ) O1 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 83 ( ) Ol [ ) 02 ( ) 03 [ ) Ol ( ) 02 ( ) 03 ( 1 OIL ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 l ) 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X1 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PEN PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. Iq PERSON FILING (SIONATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY COD[ CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID k ( ) 01 YES f ) OE NO HSC04-070185 (10/18/85) PAGE 2