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STATE ID NUMBER 00000008382008 CONTAINER CONSTRUCTION E. f ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING f 1 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER. F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE (X) 06 TAR OR ASPHALT ( 1 04 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE C ) 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) ( f 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION C 1 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT i ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE C ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHEC).ED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOPED (X) 01 ( ) 02 ( 7 03 SOLVENTS (X) 01 ( ) 02 ( 1 03 ..naie�r ru rr ( 1 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( 1 03 ( ) 01 C ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 f l 03 ( l 01 ( ) 02 ( 1 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( D 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED U THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PEP.SO F L G (SIGN R PHONE W/AREA CODE i FOR LOCAL AGEN SE ONLY AOMINISTP.ATI G AGENCY i_ CITY CODE COUNTY CODE i T► iC 3-1, CONTACT P P.SO. 0 PHONE W/AR A CODE DATE OF LAST INSPICTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT Id ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2