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STATE ID NUtJEER 000000065$6002 CONTAINER CONSTRUCTION E. f 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHL£NE WRAP ( 1 02 VINYL WRAPPING [ 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN t ) 05 NONE ( ) 06 TAR OR ASPHALT t ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: E ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: t ) O1 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) [ ) 04 PRESSURE ( 105 SUCTION (X) 06 UNKNOWN t l 07 NONE VTI LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED tES TO IV-F YOU APE NOT REOUIFED TO COMPLETE THIS SECTION CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMEPCIAL NAME ) STORED STORED f ) 01 ( ) 02 ( 103 ( ) 01 ( ) 02 ( ) 03 ( I 01 ( ) 02 ( l 03 ( 1 01 i ) 02 ( ) 03 [ ) 01 ( ) 02 ( ) 03 ( ) O1 [ ) 02 ( ) 03 ( 1 01 ( ) 02 [ 1 03 f ) 01 ( ) 02 ( ) 03 ( ) 01 f l 02 ( ) 03 ( ) 01 [ 1 02 t 1 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED Oid 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 F=LING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTPATING AGENCY CITY CODE COUNTY CODE CONTACT 'PERSON PHONE W/AP.EA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT .APPPOVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO PAGE 2 HSCC4-070185 (10/18/85)