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STATE ID NUMBER 00000012531004 CONTAINER CONSTRUCTION _ E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION { ) 04 UNKNOWN ( l 05 NONE (X) 06 TAR OR ASPHALT f ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING= ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f l 03 GRAVITY iCHECK APPROPRIATE BOX(ESI ( ) 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 (X) 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE VII LEAK DETECTION ( 1 01 VISUAL iX) 02 STOCK INVENTORY { ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) Ob GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT P.EQUIPED TO CCMPLETE THIS SECTION CUPPENTLY PPEVICUSLY DELETE CAS# (IF KNOWN] CHEMICAL (DO NOT USE CCMMERCI.AL NAME ) STOPEO STOPED __-- ( l 01 i 1 02 ( l 03 ---.- ( l 01 f ) 02 ( ) 03 — f 1 01 i ) 02 { l 03 f l 01 f ) 02 ( ) 03 I I i I I I I I U I - ( ) 01 ( l 02 ( ) 03 f ) 01 ( 102 ( ) 03 [ ) 01 ( l 02 ( ) 03 f ) O1 ( 1 02 ( ) 03 ( ) 01 i ) 02 ( ) 03 [ ] 01 [ ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS LIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO PHIS 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 # 01 YES i ) 02 NO PAGE 2 HSC04-070185 (10/18/85)