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M 4 STATE ID NUMBER 00000037605001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED f ) 02 ALKYD LINING f 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER) VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( l 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST ( ) 09 NONE ( ) 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 CAER (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED ( 1 01 ( ) 02 ( ) 03 ( 1 Ol ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( l 03 ( ) 01 ( ) 02 ( ) 03 ( l Ol ( ) 02 ( ) 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORDjJNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILI G (SI ATURE] - PHONE W/AREA CODE O �3 FOR LOCAL AGENC USE ONLY ADMIfJS STRA GENCY� A / L CITY CODE COUNT .Tfl CODE CON;TPAPERSON v /!f' T P ONE AREA CODE JT DATE OF AST ;NSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID a 430 �K6 ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2