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- STATE ID NUMBER 00000048240001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( l 01 POLYETHLENE WRAP l ) 02 VINYL WRAPPING 1 ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROFRIATE BOX ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH C ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN C ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 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 RECUIPED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STCPED STORED f ) 01 ( 1 02 ( 1 03 ( ) 01 f ) 02 ( 1 03 ( ) 01 ( 1 02 t 1 03 ( 1 01 C 1 02 ( l 03 ( 1 O1 ( ) 02 ( ) 03 ( ) 01 ( ) 02 C ) 03 ( ) 01 ( ) 02 ( ) 03 C 1 01 f ) 02 ( ) 03 ( l 01 f l 02 ( 1 03 ( 1 01 [ ) 02 ( 1 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS LISCOTAINER LOCATED CN AN AGRICULTURAL FARM? ( 1 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. PEPSON FILING IGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY U ONLY AOM'N' TEAT-NG "GPNCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/APEA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 4 ( ) 01 YES ( S 02 NO HSC04-070185 (10/18/85) PAGE 2