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STATE ID NUMBER 00000064599001 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER- F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN f l 05 NONE (X) 06 TAR OR ASPHALT ( ) 09 OTHER) VI PIPING A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN f 7 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE (X) 05 SUCTION f 1 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES 70 IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STCPED STOPED ( 7 O1 ( 7 02 ( 1 03 ( ) 01 ( 1 02 ( ) 03 ( ) al ( 1 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( 7 01 ( 7 02 ( ) 03 [ ) Ol ( 1 02 ( 1 03 ( ) Ol ( 1 02 ( ) 03 ( l O1 ( ) 02 ( ) 03 ( 1 01 ( 1 02 ( ) 03 �t CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 7 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 II ( 1 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2