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STATE ID NUMBER 00000064216002 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ] 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT [ ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLE PE ( 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WAL PIPE ( 1 02 CONCRETE—LINED TRENCH ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f ) 05 SUCTION (X) 06 UNKNOWN ( l 07 NONE VII LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YCU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STORED ( l 01 ( ) 02 1 ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 f ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) OL ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( 1 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 CoyjL ED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, 29 TRUE AND CORRECT. PERSON FILING ( UPE) / PHONE W/AREA CODE D FOR LOCAL AG NCY USE ONLY ADMINISTRATING,AG CrY, %tj , ^,G�/ CITY CODE COUNTY CODE CONTACT PERSON/ JDr,� LV �JC�'� / PHONE W/AREA CODE /?/crlA/L] Gi/Ee_s; < DA,Tt OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # 6j l ) 01 YES f ) 02 NO HSC04-070185 (10/18/85) PAGE 2