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STATE ID NUMBER 00000011242003 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04 PHENOLIC LINING [ ) 05 GLASS LINING (X) 07 UNLINED ( 1 08 UNKNOWN ( ) 04 OTHER-- 01 THER:O1 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION i ) 04 UNKNOWN (XI 05 NONE 1 1 06 TAR OR ASPHALT ( ) 04 OTHER' VI PIPING A. ABOVEGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. U)IDERGROUND PIPING: f ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( l 06 UNKNOWN I ) 07 NONE VII LEAK DETECTION ( ) O1 VISUAL fX) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT I 1 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST C 109 NONE C 1 10 OTHER VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU APE NOT PEGUIPEO TO COMPLETE 'HIS SECTION CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STOREC STCPED - ( J 01 i 1 02 ( 1 03 ( 1 01 I ) 02 ( 1 03 1 LU f 1 01 { ) 02 i 3 03 l 1 01 ( l 02 f 1 03 f l 01 f l 02 f 1 03 ( ) 01 ( 1 02 ( ) 03 ( ) 01 1 ) 02 1 1 03 C J 01 ( ) 02 1 1 03 O 01 f ) 02 1 ) 03 ( ) 01 i ) 02 ( 1 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 THE PENALTY OF 'PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, Fl—S ON FILING PHONE W.'AREA CODE -� FOR LOCAL AGENCY USE ONLY A.?,MINiSTPATING AGENOI _ CITY CODECOUNTY CODE .CONTACT PERSON f _ PHONE W,'AREA CODE CF LAST INSPECTION IN CO'1pLIdN�E ----- PERMIT opPPOVAI O4Tf TRANSACTION DATE LOC4L PERMIT :0 n Ol "ES PAGE 2 HSC04-070185 (10/18/85)