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STATE ID NUMBER 00000004741003 CONTAINER CONSTRUCTION E. ( ] 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING C ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER* F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ] 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING f ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING f 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( 1 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ] 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT f ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST l ) 09 NONE ! ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IL'-F YOU ARE NOT PEQ'JIRED TO COMPLETE THIS SECTION CUPPENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED C ) 01 ( 1 02 ( ,1_03 ( ) 01 [ 1 02 ( 1 03 ( 1 01 C ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( 1 02 ( 1 03 C ) 01 ( ) 02 ( ] 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS �I 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 (SIGNAT r9) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY / �511T CITY CODE COUNTY CODE tA CONTACT PERSON PHONE W/AREA CODE I_ !,J 1CS OATF OF LAST_`N$PECTI N IN COMPLIANCE PERMIT APPROVAL DATE TP.ANStCTION DATE LCCAL PE-`IIT ID ! Qp /YJ_ 4 ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2