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STATE ID NUMBER 00000009092002 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED 1X) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN { ) 05 NONE ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOV'EGRCUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 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) ( ) 04 PRESSURE (X1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TC IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STCREO STOPED f 1 01 O 02 ( 1 03 I I 1 ( ) 01 [ ) 02 t 1 03 ( ) 0l t 1 02 ( 1 03 ( 1 01 ( 1 02 ( 1 03 ( ) 01 ( ) 02 ( 1 03 ( ) 01 ( 1 02 ( ) 03 ( 1 01 t 1 02 ( ) 03 ( ) O1 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 [ ) 02 ( ) 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 IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( 3 01 YES ( 1 02 NO HSC04-070185 (10/18/85) PAGE 2