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STATE ID NUMBER 00000035832001 CONTAINER CONSTRUCTION [11]1(O1 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 7 05 GLASS LINING X) 07 UNLINED ( ) 08 UNKNOWN f l 09 OTHER: O1 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( I 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN [ 1 07 NONE S. UNDERGROUND PIPING: ( 7 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( 7 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION �,( 1 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f 7 05 SENSOR INSTRUMENT ( 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (XI 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV•F YOU ARE NOT REGUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STOPED STOPED (X) 01 ( ) 02 ( ) 03 111313101210171 1 1 1 1 1 XYLENE, ALL ISOMERS (X) 01 ( ) 02 ( ) 03 16171613101 ISOPROPYL ALCOHOL (2-PROPANOL) 1 1 01 ( 7 02 ( 1 03 ( ) Ol ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( 1 03 f ) Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( 102 ( ) 03 ( ) 01 ( ) 02 ( 1 03 ( ) O1 ( l 02 ( 7 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 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 INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DAT! LOCAL PERMIT ID # [ ) OS YES ( ) 02 NO HSC04-070185 (30/18/85) PAGE 2