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MEN • STATE IO NUMBER 00000048314001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. f ) 01 POLYETHLENE WRAP ( J 02 VINYL WRAPPING ( f 03 CATHODIC PROTECTION. (X) 04 UNKNOWN ( ] 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING ( ) 01. DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( 1 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 STORED ( ) 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( 1 01 f 1 02 ( 1 03 ( ) Oi ( ) 02 ( ) 03 ( ) 01 f 1 02 ( ) 0.3 ( 1 01 ( 1 02. ( ) 03 f ) Ol f ) 02 ( ) 03 ( ) 01 f ) 02 ( ). 03 • CHECK STATE BOARD CHEMICAL CODE. LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (FX) 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 7 OCAL PERMIT ID # ( ) 01 YES ( 1 02 NO HSC04-070185 (10/18/85) PAGE 2