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• • STATE ID NUMBER 00000035196002 CONTAINER CONSTRUCTION Et ) RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING f ] 05 GLASS LINING 07 UNLINED (X) 08 UNKNOWN ) 09 OTHER POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTIONIX) 04 UNKNOWN f 1 05 NONE 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN f 1 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT t ) 06GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( 1 09 NONE f ) 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOPED f ) 01 ( 1 02 ( ) 03 ( 101 ( 1 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( ) Ol t ) 02 ( ) 03 f 1 01 ( ) 02 ( 1 03 t ) Ol ( 1 02 ( 1 03 t l 01 ( 1 02 f 1 03 ( 1 01 ( ) 02 ( ) 03 [ 1 01 f ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (X) 02 NO THIS FORM HAS BEEN .COMPLETED UNDER NE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATU E) RHON W/AREA CODE FOR LOCAL AG CY USE ONLY ADMIN#?ERSON NCY `�t(y ITY CODE COUNTY CODE V1' CONTA PH E W/A A COD DATE CTION IN PLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO PAGE 2 HSC04-070185 (10/18/85)